Annual accountability hearings: responses and further issues - Health Committee Contents


Appendix 5: Government's Response - Annual Accountability Hearing with the Care Quality Commission

Introduction

On 14 September 2011, the House of Commons Health Committee (the Committee) published the report: Annual Accountability Hearing with the Care Quality Commission.

When the Committee held a pre-appointment hearing to assess the proposed appointment of Dame Jo Williams (then a CQC commissioner and acting Chair of CQC), its report indicated the Committee's intention to review the work of CQC on an annual basis, given the breadth of CQC's agenda and the vital place it occupies in regulating standards of care.

The Department strongly believes that these hearings are of great value in strengthening the accountability of the Department's independent Arm's Length Bodies to Parliament and the wider public.

Departmental response

We welcome this report and have carefully considered the Committee's recommendations and the issues it raises. The changes proposed for CQC in the Health and Social Care Bill will strengthen CQC as a quality inspectorate giving the public and patient a stronger voice.

Through the forthcoming social care white paper to be published next spring, the Department will be looking at how to drive quality improvement in social care and the role that the regulator may play in this.

The Government's response to each of the recommendations made in relation to CQC is shown in the table below. Though many of the Committee's recommendations were clearly for CQC to take forward, we have commented on all recommendations. Many of the recommendations reflect matters which have come to light in recent months and CQC already has action underway to address these. In particular, CQC has already taken action to increase its compliance activity and is taking steps to ensure that there is an appropriate balance between its registration and compliance work at all times. CQC also has work underway to refine the registration process for future tranches of registration.

Additionally, in line with the recommendation from the Committee, CQC is exploring the impact of changes proposed as a result of the passage of the Health Bill and implementation of the Department of Health's Arm's Length Bodies review. The Department will work with CQC to ensure that these changes do not adversely affect CQC's other core functions.

CQC has advised us that it will be responding in more detail on what it is doing in relation to the recommendations and so the Department has kept its response relatively high level.

Department of Health response to the Health Select Committee Recommendations - the Care Quality Commission

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.

The Government accepts the comments of the Committee and is aware of the challenges CQC has faced registering providers under the new registration framework to a challenging timetable. The Government looks to CQC as the independent regulator to undertake its regulatory functions efficiently and effectively, learning lessons from its experiences.

CQC has acknowledged that the registration process was cumbersome and that this had a negative impact on its compliance activity. CQC recognises the need to learn from this experience. CQC has assured the Department that whilst there was a reduction in the number of planned reviews undertaken, it continued to respond appropriately with responsive reviews, taking action where risks were identified.

In light of the challenges that CQC has faced in registering 22,000 providers in the last 18 months, the Government implemented proposals to delay bringing the vast majority of NHS primary medical care providers into the new system until April 2013. This delay will give CQC time to find ways in which the registration process can be improved, and to increase its compliance activity of those providers already registered with CQC.

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

The Government welcomes the Committee's analysis of the contributory factors as to why registration was prioritised over inspection and we respond to each in turn:

The CQC was originally established without a sufficiently clear and realistic definition of its priorities and objectives;

Sections 2 and 3 of the Health and Social Care Act 2008 set out CQC's functions and main objective. Its main objective is to perform its functions to protect and promote the health, safety and welfare of people who use health and social care services. Section 3 also requires CQC to perform its functions for the general purpose of encouraging improvement in health and social care services; encouraging a focus on peoples' needs and experiences of services; and encouraging the efficient and effective use of resources in the provision of services.

The Department worked closely with CQC and its predecessor bodies in developing these objectives to ensure that CQC's objectives and priorities would be clear when it took over as the regulator in April 2009.

We have made a commitment to review the role and functions of CQC within five years of its establishment. That review will take on board lessons learnt in the implementation of the Health and Social Care Act 2008 and make clarifications where these are found to be necessary to clarify CQC's role.

In terms of setting specific priorities, as an independent body, these are for CQC to determine based on the functions it has been given.

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;

In drafting the regulations to implement the new registration system, the Department of Health discussed proposals with CQC and its predecessors, and agreed a phased approach to bring providers into the new system. This brought in NHS providers into the new registration system first and then independent healthcare and adult social care providers followed by primary dental care providers. This timetable was developed following discussion with CQC. CQC was given transitional funding to support the one off task of bringing providers into the new registration system and its budget was kept under review.

The impact assessments that accompanied the regulations analysed the costs of bringing providers into the new registration system. The estimated transition costs were based on the costs to CQC of registering providers under previous legislation (the Care Standards Act 2000). Having registered around 22,000 providers in an 18-month period, CQC has carried out a difficult programme well.

However, we recognise that the one-off task of bringing independent health care and adult social care providers into registration has impacted on CQC's core functions. This is why the Department implemented proposals to delay bringing the vast majority of NHS primary medical care providers into the new system until April 2013. This delay will allow CQC to implement the lessons of previous registration rounds and to focus more on monitoring the compliance of existing registered providers with the essential levels of safety and quality.

The registration process itself was not properly tested and proven before it was rolled out; and

Whilst the Health and Social Care Act 2008 and subordinate legislation set out the registration framework, as an independent body, CQC is responsible for developing, consulting on and implementing the detailed working of the new system. We know that CQC worked with stakeholders to develop the system in advance of implementation, and CQC has made a public commitment to evaluate its model in order to improve its processes and performance management for future tranches of registration.

The CQC failed to draw the implications of these failures adequately to the attention of ministers, Parliament and the public.

Whilst the Department of Health does not get involved in CQC's day-to-day operations it expects to be kept appraised of risks and how CQC is mitigating these, including changes to the levels of inspections, through quarterly accountability meetings between CQC's Chief Executive and the Department's Director General for Policy, Strategy and Finance, and other less formal mechanisms. As part of these monitoring arrangements we expect CQC to keep the Department informed of changes to operational activity and the mitigating action being taken against any associated risks.

The Government looks to CQC to monitor and report on its performance on an on-going basis to assure the public it is carrying out its functions efficiently and effectively. The Department expects CQC to inform it in a timely manner if inspection levels drop in the future.

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.

The Government agrees that the focus on registration should not have affected CQC's compliance activity to the extent that it did. However, in order to be registered under the new system, providers were not simply "passported in" and this has meant that each provider has undergone a registration check and CQC has built up baseline information for each provider registered with it.

CQC has assured the Department that whilst there was a reduction in the number of planned reviews undertaken, it continued to respond appropriately with responsive reviews, taking action where risks were identified. CQC has now taken corrective action and the number of inspections has increased and continues to increase.

As the Committee is aware, CQC's compliance activity has been steadily increasing and it is now undertaking around 1,000 inspections a month. The Department has also been assured that CQC has taken steps to ensure a similar situation will not happen again.

By taking time now to evaluate the registration process, CQC will be able to learn the lessons from the previous registration rounds to ensure that when it brings further providers into the registration system in 2012 and 2013, registration does not have an adverse effect on monitoring the compliance of existing registered providers with the essential levels of safety and quality. We acknowledge that this tranche will bring a different set of challenges, but we have agreed to delay the registration of the majority of providers to allow CQC to develop and implement better processes.

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.

The Department has worked with CQC to find solutions within the given recruitment controls that would allow CQC to recruit to business critical posts.

Whilst the Department has been concerned by the initial delay in recruitment, we acknowledge CQC is now making much better

progress in increasing the number of compliance inspectors and the Department looks to CQC to assure the Government that it has the right workforce in post on a continuing basis, and that staffing levels do not fall to unacceptable levels thereby ensuring compliance activity is not adversely affected.

Notwithstanding the refocusing of resources on compliance, the Department of Health has now agreed a business case submitted by CQC seeking approval to recruit additional compliance inspectors and compliance managers. This approval has been given as part of the 2012/13 finance and business planning round, and CQC's indicative revenue budget for 2012/13 includes sufficient funding to allow CQC to recruit the additional 229 (full time equivalent) compliance inspectors and the additional 19 compliance managers that CQC identified as necessary.

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.

Any changes to the regulations are subject to Parliamentary process, and require formal consultation. The Department moved quickly to implement a delay to the registration of most providers of NHS primary medical providers once a request to do so was made by CQC.

CQC first raised the possibility of delaying registration of these providers in a letter of 11 March 2011 to the Secretary of State. A delay of 12 months was agreed in principle at meeting between Ministers and CQC's senior leadership team on 4 May 2011. The Department carried out a six week consultation on this proposal between 17 June and 29 July. On 12 August, the Department announced its intention to proceed with a delay to the registration of providers of NHS primary medical services. The Regulations to enable this delay have now concluded their parliamentary approval passage and been approved by Parliament.

Working closely with CQC, the Department has carried out an initial review of the regulations that underpin the registration system, responding to early lessons from implementation. Providers were registered against the full set of registration requirements for the first time in April 2010, and the Department has moved quickly to consult on preliminary proposals for changes within eighteen months. We have also made a commitment to carry out a full review of the registration system in the near future and will bring forward further changes to the regulations as required.

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.

The Government welcomes the Committee's recognition that CQC's compliance activity is increasing and recognises the importance of ensuring that the right balance between compliance and registration activity is maintained consistently even when new providers are introduced into the registration system from April 2012.

The registration of dental providers and independent ambulance services is now largely complete. This, together with the delay to registration of most providers of NHS primary medical services, will allow CQC to increase its inspection and scrutiny of those providers that are already registered.

We expect the primary medical care providers to be the last significant tranche of registration. Any future changes to the scope of regulation are unlikely to bring large numbers into registration in one go. However, we will work with CQC to ensure lessons are learnt for the future to avoid the burden of registration impacting on compliance work.

The Government looks to CQC to monitor and report on its performance on an on-going basis to assure the public it is carrying out its functions efficiently and effectively. The Department expects CQC to inform it in a timely manner if inspection levels drop in the future.

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.

The Government accepts the Committee's recommendation. The Care Quality Commission is the independent regulator of health and adult social care providers in England. While the Department of Health drew up the legal framework that underpins the registration system, the implementation of registration has been developed by CQC. We understand that CQC has piloted the process for the registration of primary medical providers when they are brought into the registration system in due course, and we would expect it to do the same for any future extensions of registration.

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.

The Department notes the Committee's expectation, and looks to CQC to report on progress to the Committee at next year's accountability hearing.

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.

The Government agrees with the Committee that it is important that resources are deployed appropriately and that it is clear how any additional resource will be used, particularly given the current financial climate. As set out above, the Department has now agreed CQC's business case requesting approval to recruit additional compliance inspectors and compliance managers.

The inspection and review process

10. 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.

The Government notes the Committee's recommendation that CQC needs to increase its inspector staffing complement and strengthen the support given to compliance inspectors. As set out above, the Department has approved CQC's business case to recruit additional inspectors and compliance managers. The Department of Health looks to CQC to monitor its staffing requirements for the future.

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.

CQC has recognised the need to "cross the threshold" of most providers at least once a year and it is currently consulting on proposals to strengthen and simplify its regulatory framework. The Department now looks to CQC to build on the regulatory model it has developed and to strengthen it in order to provide the public with assurance that providers of regulated activities are meeting, and continue to meet the safety and quality requirements and that where they are not, CQC will take action.

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.

The Government notes the Committee's recommendation. CQC is currently consulting on proposals to increase the minimum frequency of inspections and as indicated above, CQC is currently consulting on proposals to strengthen its regulatory framework. This consultation gives all those with an interest the opportunity to give their views on the proposals.

As CQC is an independent arms length body, the Department does not assess CQC's inspection or monitoring of specific providers, but monitors CQC's financial and operational performance and risks at a general and strategic level through regular formal accountability meetings. The Department looks to CQC to monitor and report on its own performance in an open and transparent manner for example through the publication of its scorecard.

13. The fact that CQC responded to a freedom of information request saying that "its systems and processes were 'not [yet] set up in such a way as to allow the reliable and robust collation of statistical information on [enforcement] activity'" 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.

The Government agrees that it is essential that CQC is able to monitor and report on the activity it is undertaking in carrying out its functions. As an organisation that has been created by merging three separate bodies, there have been challenges for CQC in bringing together three different systems. This has meant that CQC has not always been able to provide information readily. CQC has said that its new website and provider profiles will significantly improve information available publicly and the Department of Health looks to CQC to strengthen its management systems and reporting capability so that robust and transparent information is available to the public and Parliament.

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

As an independent body, CQC's approach to assuring compliance with the registration requirements is a matter for CQC. CQC has assured the Department that whilst it uses experts by experience, these are as part of an inspection team, they are not an alternative to inspection. Inspection teams may also include professionals or carers as appropriate.

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.

The tools that CQC uses to carry out its functions efficiently and effectively are primarily matters for CQC. However we ask the Committee to recognise that the availability of data varies depending on the type of provider and data for small, privately owned care homes for example, is likely to be fairly limited. For these providers, physical inspections and feedback from people using the services are therefore increasingly important in providing assurance that providers are complying with regulatory requirements. CQC has assured us that it is looking at how it can best harness this information to complement other data sources.

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.

Providers registered with the CQC must comply with 16 safety and quality requirements set out in regulations made under the Health and Social Care Act 2008. These 16 requirements include a requirement on staffing. This requires the registered provider to take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed to safeguard the health, safety and welfare of service users. The Regulations apply to providers of a wide range of services and do not therefore specify staffing ratios. CQC's Guidance about Compliance sets out how providers can comply with the registration requirements and is informed by guidance from professional bodies.

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.

The Government agrees with the Committee's conclusion. QRPs are a tool for gathering information in one place, but should not be over-relied on. The Department of Health is assured by CQC that it is not over-reliant on QRPs and that judgements are made by the inspectors themselves. QRPs can properly be used to highlight concerns that may need further examination. The Committee should be further reassured by CQC's proposals to increase the minimum frequencies of physical inspections, ensuring that there is not an over-reliance on data to assess compliance.

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.

As an independent body, CQC's methodologies and enforcement policy are matters for it to take forward. CQC is consulting on changes to its judgement framework and enforcement policy to strengthen its regulatory framework. As a national body, we would expect CQC to ensure that inspectors are acting appropriately and that there is consistency in the judgements it makes and action it takes. The Department looks to CQC to consider the Committee's recommendation.

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.

CQC's registration function requires it to assure the safety and quality of regulated activities. It does this by assuring registered providers are complying with the registration requirements which set out the essential levels of safety and quality of care that people should be able to expect and are built around the main risks that are inherent in the provision of health and social care services.

CQC responds to concerns about services but the most powerful tool to prevent abuse is to ensure that people working in health and social care do not tolerate abuse. Health and care professionals have a responsibility to make sure abuse is stopped.

The registration requirements include a requirement for providers to respond appropriately to any allegation of abuse, and to take appropriate steps in relation to a person who is no longer fit to work - including informing the relevant professional body. We are assured by CQC that in undertaking reviews of compliance, it will seek assurance that providers are complying with this regulation where it has concerns about a provider's compliance.

Whistleblowers are protected under the Public Interest Disclosure Act. CQC is a prescribed body under that act but it is not CQC's role to enforce that legislation. However, CQC considers all concerns raised with it, and has powers to take action if the information suggests a registration requirement is not being met.

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.

CQC's role is to assure the safety and quality of regulated activities. The registered provider is ultimately responsible for the quality of care it provides and how it provides it.

The registration requirements set by the Department include requirements on providers to: have processes in place for assessing and monitoring the quality of service provision; safeguard service users from abuse; and keep proper records. CQC is responsible for developing and implementing its inspection methodology on how it assures compliance with the requirements.

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.

CQC is responsible for assuring registered providers are complying with the essential safety and quality requirements, taking action where they are not. Whilst CQC encourages people to raise concerns about care providers with it, which then feed into all the information CQC holds on a provider and informs decisions about compliance activity. Whistleblowers are protected under the Public Interest Disclosure Act. CQC is a prescribed body under that act but it is not CQC's role to enforce that legislation. However, CQC considers all concerns raised with it, and has powers to take action if the information suggests a registration requirement is not being met.

CQC has published new guidance for staff and organisations on whistleblowing. The Department has been advised that CQC has also introduced a centralised system to ensure that all whistleblowing concerns are tracked from receipt through to conclusion.

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.

How CQC uses information in carrying out its functions is a matter for CQC. However, we have been assured by CQC that there are a number of actions it may take. Where concerns about the safety and quality of care services are raised, CQC will consider whether there is evidence that justifies a site visit and further regulatory action.

Where CQC is not able to take action as the concerns are not about the safety and quality of care services, and therefore the issues are outside of CQC's remit, CQC will refer the person raising concerns to the appropriate body or raise the concerns directly.

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.

The Government accepts that there were significant failures in the case of Winterbourne View. CQC has publicly acknowledged that there were indications of problems which should have led to it acting sooner, and it issued an unreserved apology to those it has let down. CQC is fully committed to learning the lessons from this tragic case and to making sure that when there are signs of poor care, it acts quickly to protect vulnerable people.

Following the events at Winterbourne View, CQC reviewed all the referrals it made to local safeguarding boards to ensure that all concerns were followed up. It also reviewed its processes for handling concerns and is making changes to improve them.

Whilst there were failures by CQC, the Government asks the Committee to recognise that there were failures by other bodies too - first and foremost the provider itself. The bodies involved in the case are all undertaking reviews and there is a Serious Case Review underway. Once these are all complete, the Department of Health will be pulling the findings together and looking at the lessons to be learned for policy and practice.

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.

HealthWatch England will have 'editorial independence' and be able to make recommendations to CQC when it has concerns about a provider. However, as an independent regulator of health and social care, CQC must make its own judgements of the risk that providers represent and the regulatory action it should take. HealthWatch England will be able to offer CQC useful advice and information, however, CQC has many sources of information to take into account when making its decisions and it must be able to justify them. It must also be free to take action that is appropriate and proportionate. It would therefore not be appropriate for the Government to specify what action it should take as a result of a recommendation by one of its own Committees, in relation to the exercise of its statutory functions.

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.

The timetable for introducing providers into the new registration was set out in Regulations that were approved by Parliament in March 2010. These put in place several waves of registration starting with the registration of NHS providers in April 2010 and ending with the registration of providers of NHS primary medical services in April 2012, now deferred to April 2013. This timetable was developed following discussion with the Commission and CQC was given transitional funding to bring providers into the new registration system. The Department kept CQC's budget under review and CQC did not request any additional resources.

The Department agreed to CQC's request for a delay to the date of primary medical care registration and has put regulations in place that achieve this.

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.

The Government's regulatory reform agenda commits Departments to review primary and secondary legislation relating to their arms length bodies. As part of this, our consultation on changes to the registration regulations confirmed our commitment to undertake a wider review of the regulations underpinning the registration system and sought views on the issues that we should consider as part of this. We will consider the responses to the consultation alongside information gathered as part of the social care engagement exercise, and issues raised with us by CQC and stakeholders. We will then draw up proposals for change and publish these for consultation next year.

Any proposals for changes will be consistent with the approach taken in the legislative framework for registration. The registration requirements are set at a high level which sets the outcomes that patients and service users have a right to expect, but are not prescriptive about how a provider should achieve these outcomes. CQC, as an independent regulator, is responsible for developing the methodology to assess compliance with the registration requirements.

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.

As the independent regulator of health and adult social care providers in England, the Care Quality Commission has been solely responsible for designing the processes to fulfil its statutory functions set out in the Health and Social Care Act 2008. The Commission is now consulting on proposed changes to its regulatory methodology and enforcement policy informed by its experience of operating the registration system since April 2010. The Department expects that in future the process for registration will be improved and streamlined.

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.

CQC will use the delay to the registration of most primary medical care services until April 2013 to review and streamline its registration processes. As set out above, we understand that CQC has piloted the process for the registration of primary medical providers already.

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.

The Department of Health has already started working with CQC, to compile a list of issues that we may want to tackle as part of the review and will engage with stakeholders to seek further views early on in the review. The consultation on changes to regulations that recently came to an end sought views on issues that the wider review should address.

We will consider any proposals to amend regulations in order to reduce the workload involved in varying registration as part of this review.

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.

The Government recognises the importance of the provision of information on adult social care providers to help people make choices about the care they purchase. CQC has recently launched its new website and we look to CQC to ensure that the information provided on it is accurate and robust.

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.

The Department of Health asked CQC to develop proposals for an award to recognise excellence in adult social care. The Department remains committed to the development of a scheme that helps people choose between providers, recognises quality beyond the essential safety and quality requirements and encourages quality improvement by providers. We now intend to use the responses to CQC's consultation to inform consideration of these issues in the "Caring for our Future" engagement that we are undertaking as part of the social care white paper.


 
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Prepared 7 March 2012