Assessing quality and performance

We consider information about the quality of care provided when we look at the 5 key questions. We provide ratings at different levels for different types of service.

We use professional judgement and a set of principles to help us to determine the final ratings.

The levels we rate are:

• Level 1: A rating for every key question at service level. For example, a rating for how safe a care home is or how effective the surgery service at a hospital is.
• Level 2: An aggregated overall rating for the service. For example, the rating for a care home or the surgery service at a hospital.
• Level 3: An aggregated rating for each key question at location level. For example, the rating for how safe a hospital is.
• Level 4: An aggregated overall rating for the location. For example, the rating for a hospital.
• Level 5: An overall rating for an NHS trust. This is based on the trust-level assessment of the quality statements under the well-led key question and moderation.

The levels we will rate each type of service

We will rate services at the following levels:

• Adult social care services: levels 1 and 2
• GP services: levels 1 and 2
• Independent doctors and clinics: levels 1 and 2
• Independent health single specialty services: levels 1 and 2
• Independent health hospital (offering more than 1 service): levels 1, 2, 3 and 4
• Online primary care: levels 1 and 2
• Urgent care: levels 1 and 2
• Non-acute NHS trusts: levels 1, 2 and 5
• Acute NHS trusts: levels 1, 2, 3, 4 and 5.

How we will aggregate ratings

Changes in the provider of a service

When the provider of a service changes, we continue to show the previous ratings on our website. We use these ratings to plan a proportionate, risk-informed approach to the first assessment after a registration change. The first assessment will make new judgements and produce new ratings. Ratings from the previous provider are not used to produce a new aggregated rating.

Read more about why and when we continue the regulatory history of a service.

Using professional judgement

If we identify concerns during an assessment, we will use our professional judgement to decide whether to depart from applying our ratings principles. We will do this particularly where we need to aggregate ratings that range from inadequate to outstanding.

When we do this, we will consider:

• The extent of the concerns
• The impact of the concerns on people who use services
• The risk to quality and safety of services, taking into account the type of setting
• Our confidence in the provider to address the concerns
• Whether the provider has already taken action.

If concerns have a very limited impact on people, it may reduce the impact on the aggregation of ratings.

We can’t predict how future models of care and configurations of services will look. To be flexible and respond to change, we will base our approach to aggregation for new models of care on these principles.

Where a rating is not consistent with the principles, we will record the rationale clearly in the report. We will review the decision using our quality control and consistency processes.

Adult social care

We rate these services at 2 levels.

• Level 1: we use our rating methodology and professional judgement to produce ratings for each of the 5 key questions.
• Level 2: we aggregate these separate ratings up to an overall service rating using the ratings principles.

Rating principles for adult social care

We decide overall service ratings using the following principles:

1. The 5 key questions are all equally important. We weight them equally when aggregating.
2. For an overall rating of outstanding, a service will normally need to have both:
   1. At least 2 key questions rated as outstanding
   2. The other key questions rated as good.
3. The overall rating will normally be good if there are both:
   1. no key questions rated as inadequate
   2. no more than 1 key question rated as requires improvement.
4. The overall rating will normally be requires improvement if 2 or more key questions are rated as requires improvement.
5. The overall rating will normally be inadequate if 2 or more key questions are rated as inadequate.

Health services

Ratings principles for health services

We follow these principles to determine how we aggregate and combine ratings.

Overarching aggregation principles

The following principles apply when we are aggregating ratings.

1. The 5 key questions are all equally important. We weight them equally when aggregating.
2. The services are all equally important. We weight them equally except where they are significantly small.
3. We treat all ratings equally when aggregating unless one of the principles below applies. We can adjust the following principles for combinations where it is not appropriate to treat ratings equally.

Aggregating ratings

We use the following principles as the basis of aggregation. We use our professional judgement to apply them to the specific combination of lower-level ratings that we are aggregating. We call these the underlying ratings.

4. The aggregated rating will normally be outstanding where:
   • The following number of underlying ratings are outstanding:
     • 1 or more where there are 1-3 underlying ratings in total
     • 2 or more where there are 4-8 underlying ratings in total
     • 3 or more where there are 9 or more underlying ratings in total
   • The remaining underlying ratings are good.
5. The aggregated rating will normally be no higher than requires improvement where the following number of underlying ratings are requires improvement:
   • 1 or more where there are 1-3 underlying ratings in total
   • 2 or more where there are 4-8 underlying ratings in total
   • 3 or more where there are 9 or more underlying ratings in total.
6. The aggregated rating will normally be no higher than requires improvement where the following number of underlying ratings are inadequate:
   • 1 where there are 4-8 underlying ratings in total
   • 2 where there are 9 or more underlying ratings in total.
7. The aggregated rating will normally be inadequate where the following number of underlying ratings are inadequate:
   • 1 or more where there are 1-3 underlying ratings in total
   • 2 or more where there are 4-8 underlying ratings in total
   • 3 or more where there are 9 or more underlying ratings in total.

How we rate NHS trusts