How we determine your aggregated ratings: NHS trusts

Complex providers

If your NHS trust delivers a combination of different service types, for example mental health services and care homes, we will assess how well your trust manages quality across the range of services and give ratings that reflect this.

Our rating for the well-led key question will reflect all of the services that your trust provides. We will use professional judgement to agree ratings for complex trusts to ensure that ratings are meaningful and proportionate. We will discuss this with you at the start of your inspection.

Merged trusts

When a trust acquires or merges with another service or trust in order to improve the quality and safety of care, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years.

During this time, we would expect your trust to demonstrate that you are taking appropriate action to improve quality and safety. We will consider this at the point of the merger or acquisition and discuss this with you at the start of your inspection. Our inspection report for the trust will clearly explain why we have not included some services in the rating.

Updating ratings

We will only review and update ratings at overall trust level following a trust-level assessment of the well-led key question and a planned inspection of core services. If we haven’t carried out an on-site inspection, the previous rating for the trust will still apply.

We will not usually inspect all services during an inspection, but the inspection report will show the date when each service was rated. If we haven’t inspected a core service or key question as part of the trust inspection, the existing rating will not change. In these cases, the report will state that after reviewing evidence about quality and safety of care, we did not identify any areas of potential concern or improvement that required an inspection.

We will aggregate ratings by combining the previously allocated ratings and new ratings from recent on-site inspection activity. Focused inspections that look at a specific concern may result in a change to a core service or location-level rating, but will not lead to a change in the overall trust rating.

After we have published the report for an inspection of core services and the well-led key question, trusts must display an updated ratings grid in relevant locations and on the trust's website.

From April 2019, where there is a change of ownership or address at an existing location, CQC’s website and internal systems will continue to display the provider’s ‘regulatory history’ (rating and inspection report). See continuing regulatory history for more information.

Using professional judgement

To ensure that we make consistent decisions, we follow a set of 16 ratings principles and apply professional judgement when rating core services, locations and providers. Our ratings must be proportionate to all available evidence and the specific facts and circumstances.

Before we start an inspection we will identify whether your trust matches one of the following scenarios, and discuss this with you:

• Is a service or location significantly different from the other services or locations? For example, its type and mix of services (including other than hospital care), size, type of setting or the population groups it serves. If yes, we may use professional judgement to decide whether to depart from the ratings principles.
• Has the trust recently taken over another service or location? If yes, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years.

If we identified concerns in the inspection we’ll consider the following criteria and use our professional judgement to decide whether to depart from the application of the ratings principles – particularly where we need to aggregate ratings that range from inadequate through to outstanding:

• The extent and impact of the concerns on people who use services and the risk to quality and safety, taking into account the type of setting and the population group. If concerns have a very limited impact on people it may reduce the impact on the aggregation of ratings.
• Our confidence in the service to address the concerns.

We can’t predict what future models of care and configurations of services will look like, so we have based our approach to aggregation on these principles to enable us to be flexible and respond to change.

The inspection report will explain in detail how we reached the rating decision.