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 actiona 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)
|