Annual accountability hearing with the Care Quality Commission - Health Committee Contents

Conclusions and recommendations

The balance between registration and compliance activity

1.  The Committee concluded that the bias in the work of the CQC away from its core function of inspection and towards the essentially administrative task of registration represented a significant distortion of priorities. Although the evidence presented by the CQC acknowledged this distortion of priorities and argues that corrective action has now been taken, the Committee believes it is important to understand how this misallocation of resources arose, not least in order to reduce the risk of the same thing happening again. (Paragraph 6)

2.  The Committee has identified the following factors which contributed to this distortion of priorities:

  • The CQC was originally established without a sufficiently clear and realistic definition of its priorities and objectives;
  • The timescale and resource implications of the functions of the CQC, in particular the legal requirement to introduce universal registration of primary and social care providers, were not properly analysed;
  • The registration process itself was not properly tested and proven before it was rolled out; and
  • The CQC failed to draw the implications of these failures adequately to the attention of ministers, Parliament and the public. (Paragraph 7)

3.  We are extremely concerned that CQC's compliance activity fell to such low levels in the course of 2010-11. We recognise that the CQC was obliged to work within the deadlines for registration imposed by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We also recognise that it was in order to meet these deadlines that resources were diverted from compliance activity to registration. Yet the fact that this was done to the extent that inspections fell by an unacceptable 70% demonstrates a failure to manage resource and activity in line with the main statutory objective of the CQC to 'protect and promote the health, safety and welfare of people who use health and social care services'. In the current climate of financial constraint and reorganisation of the health service it is more important than ever to have a regulator that maintains a clear focus on its primary duties. In this instance that did not happen. (Paragraph 15)

4.  The long-standing vacancies for CQC inspectors are a further cause for concern. The eight months taken to recruit the extra 70 inspectors for which the Department of Health gave permission in October 2010 is unacceptable given the urgent need to raise compliance activity. The CQC should also have been pushing the Government for permission to recruit outside the initial limited pool much sooner. These delays indicate a failure to react with urgency to a problem that was severely undermining the organisation's compliance function. (Paragraph 17)

5.  The CQC should have identified the difficulties inherent in the regulations early in the registration process and made clear to the Government that unless modifications were made it would not be able adequately to fulfil its duty to monitor and inspect providers. The senior leadership of the organisation had a responsibility to communicate this to the Government persuasively and persistently. The decisions to delay GP registration and review the regulations for registration have come too late. The Government and the CQC should set out what discussions were had and why action was not taken earlier to modify the regulations. (Paragraph 21)

6.  It is encouraging that inspection levels are again rising, but the challenging context for CQC work remains. Even following the Government's decision to defer GP registration until April 2013, the CQC will still need to spend 2011-12 registering the remaining dental providers and ambulance services, and then out-of-hours primary care, not to mention addressing the constant flow of applications to vary registration. The balance between registration and compliance activity will always remain an issue and if it is to maintain the confidence of the public and this Committee the CQC must demonstrate that it is prioritising its compliance activity. (Paragraph 24)

7.  Furthermore the Committee regards it as regrettable that the CQC should have launched the process of registration of dental practices without undertaking adequate proving of the registration model. It strongly recommends that each future extension of the scope of registration should be preceded by a properly planned and executed piloting process. (Paragraph 25)

8.  We expect to see clear evidence by next year of the CQC leadership openly acknowledging challenges and setting priorities that reflect its core duty to ensure the safety and quality of care. (Paragraph 26)

9.  We note the CQC's request for an additional 10% of resources to fund its inspection regime. We already have concerns about the way the CQC has handled and prioritised its existing resources and do not believe that additional resources will address these concerns unless they are deployed as part of a clear strategy. We would therefore welcome a breakdown from the CQC of how it arrived at the figure of 10% and exactly how it would intend to deploy these resources. (Paragraph 29)

The inspection and review process

10.  The CQC must seek to address growing inspector caseloads through recruitment and should also bolster the support provided to inspectors to allow them to focus on their core frontline duties. (Paragraph 31)

11.  The number of providers regulated by the CQC means that the organisation must necessarily operate a risk-based system. It is also right that the CQC should focus its resources on providers where there is an indication of a problem. However, it is difficult to see how the CQC can have confidence in a provider meeting standards if it has not visited the organisation for more than two years, no matter how good its record. Unannounced inspections must form the core of compliance assessment. (Paragraph 35)

12.  The Committee welcomes recent announcements that the CQC intends to undertake annual visits of all NHS and social care providers, irrespective of the performance of the provider. We note that the CQC is seeking to operate as a 'light touch' provider, but we do not consider an unannounced annual inspection of NHS and social care providers to be an unreasonable expectation, even for the best providers. The CQC should carefully monitor its performance against this annual target and ensure that its key performance indicators are published on a quarterly basis. (Paragraph 37)

13.  This does not give confidence in the ability of CQC central management to monitor, review and manage its compliance activity in the field, and we expect this issue to be addressed. (Paragraph 38)

14.  We welcome the CQC developing alternative assessment models that involve 'experts with experience', provided that this approach complements rather than supplants CQC inspections. (Paragraph 39)

15.  Quality and Risk Profiles have the potential to be a useful auxiliary tool for inspectors, but in their present form the quality of data is limited in its reliability and coverage. The CQC should work towards broadening the range of data included, in particular where there is little data available to support a particular outcome. (Paragraph 43)

16.  We acknowledge that the CQC operates within a regulatory framework that focuses on outcomes rather than inputs. However, low staffing ratios can have such an exceptional impact on the quality of care that we believe monitoring of staff levels is an essential part of ensuring quality outcomes. The CQC should work to develop a mechanism whereby it can keep a closer track of staffing ratios in private care homes, in a way that can feed through into the QRP. Although it would be difficult for the CQC to mandate minimum staffing levels, it should develop indicative ratios that will assist inspectors to identify potentially inadequate staffing. (Paragraph 46)

17.  The CQC must ensure its inspectors do not become over-reliant on QRPs. Even if the quality of data included in QRPs was excellent, such a tool could only ever present a patchy picture of the quality of care. (Paragraph 49)

18.  It is right that the CQC places trust in the judgement of its inspectors when assessing risks and deciding on appropriate action. But this judgement can only be consistently exercised if the CQC provides a clear framework and guidance. It would be easy for active inspection activity to regress at this time of increased pressure on inspectors. The CQC must therefore ensure there is a consistency of approach by reiterating risk thresholds (Paragraph 50)

19.  In its recent reports on the work of the General Medical Council and the Nursing and Midwifery Council, the Committee emphasised the importance which it attaches to the obligation which rests on all healthcare professionals to raise concerns if they recognise, or ought to have recognised, evidence of failure of professional standards. The Committee believes it should be a key objective of CQC inspections to ensure that the culture of each provider organisation recognises and respects this professional obligation, and provides proper security to those professional staff who discharge it effectively. (Paragraph 52)

20.  Although healthcare professionals have a particular obligation, arising from their professional status, to take an interest in the quality of care being provided around them, this obligation is, in truth, a particularly focused form of the general duty of care owed by all staff of care providers to their patients, and indeed of the natural human desire of all citizens to see high quality care provided to the sick and vulnerable. Information is available from all these sources to measure the performance of care providers. The Committee believes it should be a key part of the inspection process to ensure that proper processes are in place in each care provider, including proper Board accountability, to ensure that these responsibilities are met. (Paragraph 53)

21.  The calls coming in following Winterbourne View could be only the tip of the iceberg. We look to the CQC, in addition to encouraging cultural change within care providers, to take action to encourage direct information supply in cases where local structures fail. (Paragraph 56)

22.  The CQC must ensure it makes the most of information provided to it. All relevant communications should be followed up in order to establish the usefulness of the information and to inform the CQC's own judgement. This sort of information should be a trigger for CQC action—a note appearing on the QRP is not enough. (Paragraph 57)

23.  Action in the case of Winterbourne View was woefully inadequate: the CQC failed to 'actively follow up' the local authority process, or conduct its own assessment, or even contact Mr Bryan for further information. The CQC should have done all of these things. (Paragraph 58)

24.  The Committee believes that the CQC should be obliged to carry out an investigation in response to a recommendation from its HealthWatch sub-committee that the CQC investigate the quality of care provided by a particular provider. (Paragraph 62)

The registration process

25.  The Committee has already reported its views that the priority attached by the CQC over the past 12 months to the registration of new providers represented a distortion of priorities. If this extension of registration activity was required management should have ensured that it was resourced in a way which did not affect the core existing activity of the CQC and should have resisted pressure from ministers or elsewhere to adopt a registration policy which it is now clear was inadequately prepared or resourced. (Paragraph 63)

26.  The current regulations governing registration have imposed difficult and occasionally inflexible restrictions on the CQC's procedures. It is regrettable that this was neither foreseen nor addressed before the vast majority of providers had already fought through the process. Nevertheless we welcome the Government's review of the regulations. We urge the CQC and the Government to work closely together and with providers during this consultation period to ensure that all future registrations (and in particular that of primary care providers) can be conducted in a proportionate manner within adequate timeframes. (Paragraph 72)

27.  The CQC must also accept responsibility for its poor handling of registration and adapt its processes accordingly. In particular, the process could have been made significantly simpler and swifter for all involved had the CQC adapted registration procedures to different types of services. It is astonishing that it could ever have been considered sensible for small dental practices to work through the same process as a large hospital. (Paragraph 73)

28.  Following the postponement of the deadline for registration of GP practices until April 2013 the Government and the CQC have some time to put things right. But this is no time for complacency. Action must be swift if procedures and especially regulations are to be reviewed, altered and put into practice in good time. We expect to see significant progress on this matter by the time of our next accountability session with the CQC. (Paragraph 74)

29.  It is right that the CQC approval should be required for significant variations to registrations, but this requirement will remain a significant burden on both providers and the CQC unless the procedure is greatly streamlined. We welcome the action the CQC has already taken to improve the system and bring processing times down to a more reasonable level. The CQC should do all it can within the regulations further to improve the procedures, including consulting with providers and professions and bringing forward development of a system of electronic submission and processing. The CQC must work closely with the Government's review of the registration regulations to identify where changes are necessary. (Paragraph 78)

Provision of information to the public

30.  The information currently provided by the CQC on adult social care providers is unhelpful and often out of date. We welcome the introduction of an 'under review' label where the CQC is investigating a provider, but we find it surprising that it has taken so long to provide the public with such essential information. The delay in developing provider profiles is particularly frustrating as they could have been a useful interim guide for the public until a successor is developed for the star rating system. The constant slippage in the planned roll-out of the profiles is further evidence of a lack of control within the organisation. (Paragraph 84)

31.  The proposed Adult Social Care Excellence Award has been roundly rejected in evidence submitted to us. We share these concerns and recommend that the project is dropped. (Paragraph 87)

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Prepared 14 September 2011