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