Memorandum submitted by the Care Quality
Commission
INTRODUCTION
1. Established by the Health and Social Care
Act 2008, the Care Quality Commission is the regulator of health
and adult social care in England. We register and inspect providers
of services including the NHS and private and voluntary healthcare
and our regulatory model requires organisations to comply with
a set of essential standards of quality and safety.
2. The scope of registration currently applies
to the NHS and to private, voluntary and community interest companies.
Dentists will be required to register by April 2011 and independent
doctors and GPs from April 2012.
3. One of CQC's core strategic aims is to regulate
effectively, in partnership, and CQC and its predecessor, the
Healthcare Commission have been working with Ofsted (and its predecessor
inspectorates) for over five years to align our inspection programmes
as they relate to children health and welfare. This joint work
has primarily been related to inspection of children's social
care, and our submission below reflects our experience of this
aspect of Ofsted's work the merger in 2007. We have had little
relevant experience of Ofsted's involvement in the inspection
of education or early years childcare services.
PARTNERSHIP WORKING
4. Our main programme of joint inspection activity
has been the Integrated inspections of children's services with
which the Committee will be familiar—CQC are the only partner
and we have fielded at least one inspector to each of the 33 inspections
completed to date, of which 31 have been published.
5. This follows the multi-inspectorate Joint
Area Review programme, building on the learning but striving to
reduce the "burden" of inspection on authorities and
their partners and improve the focus and clarity of the inspection
activity.
6. CQC's involvement in these inspections is
crucial in order to provide an inclusive view of how health services
are working in partnership to improve outcomes for children and
interpret the complexities of processes and approaches across
a range of health care providers. We gather evidence and information
about providers of services which contributes directly to our
judgement framework and assessment of compliance with Essential
Standards of Safety and Quality, but also contribute fully to
sharing evidence and findings with Ofsted colleagues.
BENEFITS OF
JOINT INSPECTIONS
7. The programme has high impact within local
authorities and health partners, and an "inadequate"
finding, particularly for overall safeguarding or capacity to
improve usually results in a form of attention or intervention
from Government office or DfE. Increasingly the contribution of
health partners to the outcome is being considered pertinent and
we have found that the inspections can expose areas both where
there is effective partnership working and also where co-operation
could be significantly improved amongst local agencies - there
is no other vehicle at present to achieve this, and a CQC-badged
report is taken seriously by SHAs and health organisations which
can stimulate rapid and effective improvement.
8. The findings reflect both where social care
is excellent but health partners may be experiencing challenge,
and also the converse - good health relationships and effective
working that are hampered by pressure within the Authority. Since
partnership work is essential to effective child protection, particularly
in early intervention and access to vulnerable families, we work
with Ofsted to examine evidence where one partner has indicated
that others are "not pulling their weight" so that our
joint report reflects a true picture of an area's services and
responsibilities for children.
9. Without the involvement of Ofsted in these
inspections, and the leadership of the programme as a whole, it
is unlikely that there would be any substantive routine inspection
of integrated safeguarding and child protection arrangements which
includes health care organisations as partners in a wider system.
The two-week cross-organisation inspection model is not one which
CQC use routinely in other areas of our work, although there is
scope for individual compliance reviews against standards where
concerns are raised about individual providers.
10. Our work with Ofsted over five years has
resulted in a strong methodology, a clear understanding of our
mutual procedures and arrangements and, we feel, an increasingly
integrated approach to joint inspection. The short notification
period ensures that we see organisations "how they are"
but also we often note that the prospect of an inspection does
facilitate improved working together across partners towards a
common objective.
11. Onsite, Ofsted demonstrate an extremely professional
and systematic approach to evidence gathering and evaluation,
although the detail and structure of the fortnight can depend
heavily on the individual Lead Inspector. Judgements are made
by consensus only after full and frank discussion including CQC
team members, and all inspectors stand by the agreed judgements
and will defend them rigorously.
12. With the changes proposed in the health White
Paper, and increasing pressure on local authorities it is important
that there is a process to monitor the quality of child protection
arrangements across partnerships of services and ensure that there
is a mechanism to report any likelihood of services putting children
at risk.
13. This needs to be a lean programme, and staff
working on the inspection teams are extremely diligent and thorough,
which is widely acknowledged by those who have experienced an
inspection. Findings and likely judgements are explained and
shared during the inspections and feedback is received and acted
upon where appropriate by both ourselves and Ofsted.
AREAS FOR
DEVELOPMENT
14. We appreciate there is challenge from some
quarters on the need for external inspection at all, and whether
in resource-stretched times less or no inspection is proposed.
15. The integrated inspection programme has so
far identified a significant number of services which are considered
inadequate, and follow up inspection has noted progress as a result
of intervention triggered by inspection findings. It is not clear
how these would have been identified by other means.
16. There is greater scope for use of peer reviewers,
but his has been slow to establish because of the need for training
and induction in order to acknowledge the inspection process and
contribute effectively. Similarly, involving Children or young
people as inspectors has been explored a number of times during
the five years we have been working with Ofsted but it has unfortunately
proved too costly and complex to justify the clear benefits of
involvement.
17. We are about to publish, jointly, a revised
framework and handbooks for inspection which reflect the feedback
we have received over the first year of the programme. It provides
a better balance between thoroughness and burden and we have been
impressed by the flexibility that Ofsted have shown in acknowledging
the regulatory model of CQC and incorporating it throughout the
framework.
LOOKING AHEAD
18. Working in partnership for these inspections
works. The challenge of different approaches which reflect the
different models of provision and governance arrangements in inspected
services is helpful and maintains rigour and quality judgements.
19. We are aware of the tremendous impact of
structural or organisational change on an organisation and particularly
on the front line people within it when systems change, aims and
objectives are reviewed and "business as usual" is challenged
at all levels.
20. With the changes affecting local government
and health at the present time there is a real benefit in organisational
stability within a regulator, enabling us to build on existing
knowledge and relationships and ensure a consistent inspection
programme within an increasingly changing environment.
21. In terms of CQC's involvement with the programme,
this is a valuable opportunity to conduct a "deep dive"
into a specific area of care, scanning several organisations across
a number of our Essential Standards which complements and adds
richness to our usual compliance work. If the inspection programme
were to cease then the depth of our knowledge about children's
healthcare provision would be significantly reduced as there is
currently no capacity or remit for CQC to conduct such focused
activity on a routine rolling basis through other means.
Annex
BRIEF SUMMARY OF HEALTH STRUCTURES
Within a local authority the term "health contribution"
is often cited, for example to joint working groups or investigations,
but many are unclear of what this means. There is usually one,
but may be up to three Primary Care Trusts contributing to a single
authority or a PCT may cover two authorities.
PCTs commission services across all healthcare for
their population but usually host a provider service arm, covering
(for children) school nursing, heath visiting etc. GP services
are commissioned by the PCT as are A&E, maternity and acute
(hospital) care. Other emergency care activity such as walk in
centres may be run by acute or community services. Mental health
for adults and CAMHs services may be covered by a specialist mental
health trust that holds contracts with several PCTs. Community
health services, such as those for disabled children, may be co-funded
with the authority or external partners. Each of these discrete
providers contributes to "health" in an area and CQC's
own inspection and monitoring processes can gather relevant data
to hold providers of services to account.
CQC's approach to planned inspection for children
takes the form of a "compliance inspection" mapping
our findings for each partner organisation against our own Essential
Standards under the expected outcomes. We also contribute towards
an overall judgement for health partners within the area, led
by the commissioning role of the PCT(s).
October 2010
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