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

Appendix 6: Care Quality Commission's Response

The balance between registration and compliance activity

1.  Paragraph 1 - Prioritisation during transitional registration

1.1.  CQC acknowledges that there were difficulties for providers in the transitional registration process and we have apologised for a number of issues which arose. The external pressures under which CQC was operating and their impact on its priorities have been well-rehearsed, including in Dame Jo Williams' letter to the Committee's Chair of 30 June.

1.2.  CQC has published figures that make clear that compliance activity was significantly affected by transitional registration, particularly that of adult social care providers. This was by far the largest piece of registration the Commission faced and it was this that had the most significant impact on CQC's work - and not dental registration as the Committee has suggested.

1.3.  It is worth emphasising that transitional registration is a one-off process by which existing or new sectors are brought in to the scope of CQC's governing legislation in a large single 'tranche' (a batch of registration - e.g. the registration of the NHS was 'tranche one'). This large-scale processing is significantly different to 'business as usual' registration - a process by which, for example, new care home would register with CQC.

1.4.  This means the NHS, adult social care, independent healthcare, private ambulance services and dental providers will never again have to go through sector-wide registration under this legislation.

1.5.  Transitional registration was, in itself, a check of a provider. The Health and Social Care Act 2008 brought with it a new set of regulations, and in order to register providers against them we needed to satisfy ourselves they were compliant. Our checks did not always involve a site visit, and did not result in a detailed report, but no service was left unchecked and the fall in inspections needs to be seen in this context.

1.6.  During transitional registration CQC continued to respond to signs of risk as and when they were identified. Responsive reviews and enforcement action continued during this period, including under the Care Standards Act 2000 (which was in force for adult social care and independent health until 30 September 2010). Although inspection levels fell, poor care was not ignored.

1.7.  The Committee's report highlights the problems that were faced in the earlier tranches of registration. CQC now has breathing space as a result of the delay in the registration of primary medical services. We have learned a great deal about registration - both the process of bringing new sectors into CQC's scope, and of bringing in new providers as part of 'business as usual' - and have made significant improvements in performance in this area.

1.8.  CQC continues to consider the impact that taking on new and additional responsibilities may have on its core business and will seek to ensure that these impacts are always made clear to stakeholders. This includes raising concerns with Ministers when appropriate. For example, the Chair of the Commission wrote to the Minister of State for Health Services, Simon Burns MP, on 31 October to raise concerns about the possible impact of CQC's taking on some functions of the HFEA and HTA [ANNEX 1].[22]

2.  Paragraphs 2 and 7 - Piloting transitional registration

2.1.  The Committee's report makes specific reference to planning and preparation for transitional registration. We would like to set out some of the background that went into this.

Early testing

2.2.  From early 2009 onwards CQC conducted a series of pilots covering the transitional registration process and the processes and documentation for the monitoring of ongoing compliance. These included pilots with service providers who were going to be registered and workshops with provider representative bodies.

2.3.  In August and September 2009 we conducted a focused pilot of the transitional registration process. One key aim was to capture and incorporate into registration the views of providers as well as those of our inspectors and assessors.

2.4.  The testing involved 21 providers from the North West, which ranged from large NHS trusts to small providers with one care home or clinic. The providers included those from the private, voluntary, and public sector. The quality of service they provided to service users at the time varied. The feedback from the pilot was used to improve our registration documents, tools and guidance.

2.5.  Due to time constraints, pre-launch testing was limited to assessing the technical processes that underpinned transition, rather than testing under full operational conditions. There was no time for extensive testing of the technical system in a 'live' environment before it was launched. The role of our national processing centre, National Customer Service Centre, and allocation for processing applications had to be tested when registration was more developed.

2.6.  In October 2009 an Office of Government Commerce Gateway Review was conducted by the Department of Health into the CQC transitional registration programme. It made a number of recommendations for the registration programme given the very tight timescales and also identified areas of strength.

2.7.  Strengths included the programme's comprehensive and effective governance arrangements, and exemplar best practice engagement with internal and external stakeholders, including on the co-production of documents and processes.

2.8.  This early stage testing was completed against tight timescales and against other constraints and demands (e.g. continuing to regulate social care under the Care Standards Act 2000), including a lack of certainty over the affirmative regulations to underpin registration which were not submitted to Parliament until a late stage.

Improving the process

2.9.  We have sought to apply the learning from one transitional registration tranche to the next and improve our methods and guidance. It is, however, important to note that the three tranches to date have been fundamentally different from each other. Additionally, the need for the application window to open for adult social care registration in April 2010 - the same month we concluded NHS registration - meant there was limited scope to apply the learning from the NHS to adult social care and independent health.

2.10.  We carried out a 'lessons learned' exercise and an internal audit after the first two tranches (NHS and adult social care / independent health). In light of this we sought to modify and simplify our application process. This enabled better planning and monitoring of resources and meant that CQC delivered dental and private ambulance registration (for April 2011) without affecting front line inspection activity.

2.11.  We have looked at our processes to see how these could be refined to meet the twin objective of safeguarding people who use services while improving the provider's experience of registration. Examples of this include assessing the value of medical, professional and personal references for applicants. These checks were time consuming for both the applicant and CQC but did not add significant value. This has resulted in us making improvements to the application form and providing guidance to our staff as to the circumstance under which such references should be taken.

2.12.  The greatest opportunity to implement learning and deliver improvement comes between dentists and primary medical services (including GPs), which are the most similar sectors (in terms of configurations of services) and share the same transitional arrangements. Now that we have secured a delay in primary medical services' registration to April 2013 we are making the most of this opportunity.

Dentists and private ambulances - pilot details

2.13.  The Committee makes specific reference to the lack of adequate piloting of the model ahead of dental registration. We would like to provide more detail about our work in this area.

2.14.  In summer 2010 we conducted a transitional registration pilot with 17 primary dental care services across three PCT areas. Providers used guidance provided to complete and submit a provider application and declaration form and a registered manager application form, if applicable. As a result of the pilot we improved our documentation and advice in a number of areas, including legal definitions of dental partnerships and associates, signposting the regulated activities most dentists needed to apply for and where certain declarations were required. A similar pilot was also undertaken with six independent ambulance providers in summer 2010.

2.15.  We had an advisory group for the registration of dental providers. Members of the group included the British Dental Association, General Dental Council, Department of Health, Royal College representatives, Denplan, individual dental providers and others. The group met regularly from spring 2010 until June 2011. The meetings were used to give updates on CQC's progress both in registration and the compliance pilot as well as for stakeholders to share concerns. In addition more detailed meetings were also held with individual stakeholders to discuss items such as information sharing, working together and other matters they brought to CQC's attention.

2.16.  We did use the time ahead of dental registration to develop new policies to improve our risk assessment. A lighter-touch process was developed whereby assurance from Primary Care Trusts (notably Criminal Records Bureau checks) was accepted and we encouraged online processing. We registered 8,000 dental providers without diverting resources from inspection and inspection rates increased rapidly during this period. Coordination with Primary Care Trusts did not work as well as planned, partly due to their reorganisation.

Improving registration overall - transition and business as usual

2.17.  Looking ahead, we are further refining the processes for primary medical services and for all future registration activity through a full end-to-end review of our registration processes. This review started in November 2011 and is focused on further refinement to the changes we have already implemented, and to seek to improve the provider's experience of the registration process while maintaining a focus on safeguarding users.

3.  Paragraphs 3, 6 and 11 - inspection activity and frequency

3.1.  As the Committee highlighted, CQC's inspection activity reduced during the period of registration of adult social care providers. The registration model at that stage involved using inspectors and therefore reduced their capacity to undertake routine inspections. We learned lessons and made changes for dental and private ambulance registration, which was delivered without any detrimental effect on inspection activity.

3.2.  No front-line inspection staff will be used in the delivery of transitional registration for primary medial services (including GPs) in 2013.

3.3.  Our new compliance model, to be introduced from April next year assuming a positive response to our current consultation (see paragraphs 6.1 to 6.4) will see an inspection at least once every business year of all registered hospitals, care homes and domiciliary care providers. We will carry out an inspection of all registered primary dental services and primary medical services at least once every two years.

3.4.  These inspections will be unannounced unless there are exceptional circumstances (e.g. entering a one-to-one environment between a professional and patient; or the need to interview a specific member of staff). This is now and always has been CQC's position on inspections.

3.5.  A table showing completed reviews of compliance of regulated services by sector since the creation of CQC is attached [ANNEX 2].[23] It indicates how many of these involved a site visit. In all but exceptional cases, these are unannounced visits in line with existing policy.

4.  Paragraph 4 - Vacancy levels and requests to recruit outside the NHS

Current and future compliance inspector vacancy levels

4.1.  CQC expects to have a full complement of compliance inspectors by the end of January 2012. We have interviewed and made offers to fill all but 25 compliance inspector posts, and more than 50 new inspectors are already in post. We are pleased that our relationship with the Department over recruitment is much improved.

4.2.  In the most recent recruitment round CQC received over 3,500 applications for the 50 posts advertised on 14 July 2011. In addition to those offers made, we identified sufficient talent to fill over 200 further compliance inspector posts.

4.3.  On 27 October 2011 we received approval for our business case to employ further inspectors above our current establishment level, as discussed with the Committee (see paragraphs 8.1 to 8.6). We have plans in place to conduct the final assessment, recruitment and induction of additional compliance inspectors above our current establishment target to take advantage of this. We are now contacting the applicants identified to invite them to the final recruitment assessment centre.

4.4.  We have looked at how our new compliance model will operate and how many inspectors will be required. More than 400 operations employees (including those piloting the new compliance model) have been completing time sheets as they undertake their regulatory and other tasks. This provided an accurate picture of the resource required to operate both our current and proposed compliance models.

4.5.  Compliance inspectors have also supplied a number of comments and innovative ideas about managing their role, their professional views on good inspection practice, and what makes for a manageable portfolio.

4.6.  Our judgement is that we need 950 compliance inspectors for the new compliance model to work effectively in 2012/13. This would provide a reduction in average portfolio size, excluding primary medical services, to just over 40 locations per inspector. Including primary medical services this will increase to just over 45 locations per inspector, based on the current predicted number of locations due to register with CQC.

5.  Paragraph 5 - Correspondence with the Department of Health regarding delaying primary medical service registration and the review of the regulations


5.1.  CQC has always met the Department of Health regularly and has kept officials there fully informed of problems in implementing regulations. This has included weekly reviews at senior level during key points in the transitional registration application periods.

5.2.  Given the scope and scale of the legislation, it is not clear that there were opportunities to make changes to the regulations ahead of transitional registration. Amending the regulations for primary medical care provider registration (the GP tranche) took nine months and required exceptional procedures to speed through the process, including shortened public consultation and cross-government clearance periods.

5.3.  In the case of adult social care registration, had we asked the Department to amend the regulations on 1 April 2010 (the day CQC's regulations came into force and before we had any experience of implementing them) it would not have affected our adult social care registration deadline of October 2010. As stated above, it was this tranche of transitional registration that had an impact on inspection.

5.4.  We raised concerns about the impact of the regulations on transitional registration with the Department on various occasions and formally wrote to the Secretary of State in March 2011 to ask for a delay to give both us and GPs more time to prepare for their registration [ANNEX 3].[24]

6.  Paragraph 6 - Balancing registration and compliance work: revising our Judgement framework and Enforcement policy (September 2011)

6.1.  We have learned a lot about our model in the past 18 months from listening to the public and providers, and through thousands of inspections, and it has been clear that we can make improvements to the way we register and inspect services. Improvements in our model will better enable us to balance the challenges of registration and compliance, notwithstanding comments on this already made.

6.2.  In September we opened a public consultation on improvements to our regulatory model. This closes in December and we have included our consultation document [ANNEX 4].[25] This consultation sets out proposals to move to more regular inspections, and to be clearer about whether providers are or are not meeting the essential standards. We want to simplify and strengthen the model and remove some of the ambiguity in the current judgement framework. This should help providers and the public understand what our view is, and should also deliver more consistency in our judgements.

6.3.  Almost all of the changes we are suggesting are a direct result of feedback from care providers, members of the public, CQC's inspectors, and from trade associations. We hope the proposals will be welcome, although we will of course consider any further views that come to light through the consultation process. The consultation's proposals, if adopted, will come in to force from April 2012.

6.4.  As part of our consultation we are piloting changes to our compliance model to ensure we make the best use of our resources. Rather than assessing all providers against all 16 outcomes, inspectors are piloting an approach where we focus on the most appropriate outcomes for the service type, and use information we have about risk at that provider, to carry out a targeted inspection. This allows our inspectors to focus on the most relevant outcomes and make the best use of their (and the providers') time.

7.  Paragraph 8 - leadership and priority setting

7.1.  Jo Williams' covering letter with this appendix sets out some of CQC's core priorities for the year ahead. The Commission has robust business planning processes and procedures in place, including a range of measures to publicly demonstrate performance against targets (see section 10).

7.2.  Priorities and progress against these are subject to regular internal scrutiny at Board and executive level, and to external scrutiny via quarterly director level meetings with the Department of Health, and quarterly accountability meetings between CQC's chief executive and the Department's Director General of Policy, Strategy and Finance. Regular meetings also take place between CQC's chair and chief executive and Ministers, the NHS Chief Executive, and the Department of Health's Permanent Secretary.

7.3.  Dame Jo looks forward to updating the Committee in CQC's annual accountability hearing in 2012.

8.  Paragraph 9 - Request for further resources to fund improvements to the regulatory model

8.1.  On 16 June 2011 Dame Jo Williams met the Minister of State for Health Services, Simon Burns, and informed him that CQC continued to look for efficiencies. Dame Jo told the Minister CQC was undertaking a detailed analysis of inspector caseloads but on the basis of risk CQC was considering the need for more inspectors.

8.2.  On 12 August 2011 CQC sent the Department of Health a business case outlining efficiency savings we propose to make and requesting further resources to fund improvements to our regulatory model.

8.3.  The strategic principles that underpin our future resourcing model are as follows. Where we refer to inspections, these will be unannounced in all but exceptional cases at all times (as is currently the case).

8.3.1.  Either a scheduled, responsive or thematic inspection each business year, for most adult social care and independent healthcare services; all NHS acute hospitals; all NHS Ambulance Trusts; and at least one service type in all other trusts and at least once every other business year, carry out either a scheduled, responsive or thematic inspection of all primary dental and primary medical services.

8.3.2.  Our inspectors will have an in-depth knowledge of the services in their portfolio. This is supported by our regulatory model and the intention to reduce the size of an inspector's portfolio.

8.3.3.  During our inspections we can be accompanied by people who are experts in certain aspects of care, (for example maternity) and/or by people who have extensive experience of using care services, who we call Experts by Experience. They supplement our inspection activity, not supplant it.

8.4.  The proposed resource model with increased inspection activity and lower inspector caseload will require 950 compliance inspectors. This is 200 more full time equivalent inspectors and 20 more full time compliance managers than we have at present.

8.5.  This will increase our operating costs by around £15m per year from 2012/13. This is the basis for the 10% increase on existing budget that was discussed at the Committee.

8.6.  However, we plan to deliver additional efficiency savings in 2012/13 to the value of £5m. The additional £10m will be financed by an increase in Grant in aid from the Department of Health (although this includes funding for HealthWatch England). Our business case received written approval from the Department on 27 October 2011.

Future context

8.7.  Factors outside CQC's direct control can, of course, affect our use of resources. Regulating poor care is far more resource-intensive than regulating compliant care. The standards of evidence required, legal preparation for enforcement, and follow-up needed to check whether action has been taken means that any increase in the overall prevalence of poor care will have a direct impact on CQC's performance.

8.8.  A good example of this is our activity at Barking, Havering and Redbridge NHS Trust. Since registration against the Health and Social Care Act 2008 in April 2010, we have carried out eight unannounced inspections, which amount to 31 days in the Trust's hospitals since April 2010.

The inspection and review process

9.  Paragraph 10 - Inspector caseload and support

9.1.  CQC is actively monitoring the size of inspector caseloads. We are working to ensure caseloads are at a manageable level through recruitment, improvements to our compliance model and making our internal systems more efficient.

9.2.  A range of support from specialist clinical advice to legal support is available to inspectors. We are currently developing and extending the use of clinical and professional 'expertise' in our regulatory activity.

Improvements to the compliance model and streamlined processes

9.3.  There are a number of improvements within the new compliance model that will speed up the inspection and report writing process. This is designed to make inspector caseloads more manageable.

9.4.  We have focused on improving our report writing tools and methodology, aspects which can take up to 25% of an inspector's working time. The system we currently use to capture reports is being modified from November 2011. Testing and training will follow thereafter, with an expectation that the system is implemented from April. Reducing report writing by just two hours per report for adult social care services would achieve a 10% reduction in the time taken to carry out a review - freeing up more time for more inspections.

Support for compliance inspectors

9.5.  All compliance inspectors have access to the following guidance resources to support them in their regulatory work:

9.5.1.  Compliance inspectors - where necessary compliance inspectors can call on the support of other compliance inspectors, for example where a larger team of inspectors is required to carry out a visit.

9.5.2.  Compliance managers - line managers are able to offer day to day advice and support to compliance inspectors, including regarding appropriate regulatory action in the individual circumstances of each service.

9.5.3.  Guidance documentation - the CQC intranet includes a library of underpinning documents and advice, including items such as 'how to request support from a Pharmacist regarding a medicines risk at a service'.

9.5.4.  Senior analytical advisers and regional intelligence and evidence officers - regional intelligence teams provide support to compliance inspectors in interpreting data to analyse risk and support regulatory judgements.

9.5.5.  Experts by experience - inspectors can call on people who have recent experience of care in a given setting to attend an inspection with them to provide a more patient-centered view of the care provided.

9.5.6.  Specialist advice - professionals and clinicians who currently work in front line posts which inspectors can call upon for specific or clinical advice. We have national leads on safeguarding, healthcare associated infections and pharmacy available to assist and advise.

9.5.7.  National Professional Advisors - some of our professional advisors also provide sector-specific and clinical advice to compliance inspectors as required.

9.5.8.  Legal advice - our legal team is on call to provide advice to compliance inspectors and managers where required in the course of their regulatory and enforcement activity.

9.5.9.  Training -  On joining the Commission all compliance inspectors undertake an eight week induction and training programme, including shadowing with experienced inspectors. New inspectors are also supported through a buddy system in addition to their line manager. In their individual reviews at the end of the induction programme new inspectors discuss bespoke further training needs. This is delivered before the end of the inspector's probation period (six months into post). The programme has been well received:  "In addition to learning about the procedures and tools we will be using, we also spent a day or two a week shadowing inspections in our regions which were a great introduction to the practicalities of the job and an opportunity to meet some of our colleagues." Tim Brackpool, Compliance Inspector  Training after probation is undertaken by inspectors when required based on business priorities and changes to our methodology, guidance and systems. Inspector training requirements are also identified and monitored by line managers through our performance and development review process, with refresher courses and further training available.

10.  Paragraphs 12 and 13 - Key Performance Indicators

10.1.  CQC has made significant progress in developing effective performance indicators and enclosed is the latest performance scorecard [ANNEX 5].[26] This is published on our website on a quarterly basis and includes data on our inspection performance against our internal targets.

10.2.  The scorecard is underpinned by more frequent weekly and monthly reporting on progress to the Operations Management Team meetings and the CQC executive team. A scheduled programme of inspection activity ensures everyone is clear about all the inspections that are required by our own internal targets.

10.3.  The targets under our current methodology are to inspect 100% of NHS providers; 62.5% of adult social care and independent health care locations; and 15% of dentist locations by March 2012. These targets are based on the date each sector came into regulation and the need to inspect at least once within two years of registration, and the capacity available to carry out the programme.

10.4.  Targets for 2012-13 are being developed against the new model of compliance to be introduced next year.

Developing our Key Performance Indicators

10.5.  Our key performance indicators and supporting management information systems have been developed since 2009 against a background of CQC's changing remit, roles, and transfer between data systems. An audit of our performance framework reported earlier in 2011 and was positive about our approach, the progress and improvements we have made and plan to make, and the developments we are taking forward.

10.6.  We have made a number of data quality improvements this year, and as part of this programme (from November 2011) we have fully automated collection of data on enforcement. This will make it possible to deal more effectively with information requests for enforcement data for future periods which require national analysis or collation.

10.7.  In summer 2011 we worked to improve the reliability of information on numbers of compliance inspections completed. We are now reporting publicly on our performance against our own internal targets of inspections required for each sector, as based on the date each sector came into regulation and the need to inspect at least once within two years of registration (under our current methodology).

10.8.  During the early part of 2011 we focused on developing more reliable information on the processing of new and variation registration applications against a target of eight weeks for processing. This target halves the time which our predecessor bodies took to carry out similar processes.

10.9.  We continually work to develop our suite of performance measures. We are currently looking to include more outcome based measures in our scorecard, such as reporting on the numbers of compliant vs. non-compliant providers; the numbers of inspections resulting in compliance or enforcement actions; and the time taken to move non-compliant providers into compliance. This is likely to involve some further work to our management information systems. We also want to broaden the scorecard and evaluation activity further into areas of quality and impact measurement.

11.  Paragraph 14 - Experts by experience

11.1.  We welcome the Committee's support for CQC's use of 'experts by experience.' They played an important role in our 'dignity and nutrition' inspection programme and we intend to expand our use of them in 2012. At present, we are making active use of experts in our reviews of learning disability services prompted by Winterbourne View. We can confirm that these experts are additional to our core inspection workforce and are not intended to supplant CQC's work.

12.  Paragraphs 15 and 17 - Quality and Risk Profiles

12.1.  We are pleased to reassure the Committee that the quality and risk profile (QRP) is a tool that aims to gather what we know about a provider in one place, enabling us to assess where risks may lie and prompt front line regulatory activity, such as inspections. QRPs are not a judgement on compliance or a substitute for inspection. We would welcome the opportunity to demonstrate the QRP to members of the Committee and, crucially, to explain the part they play in our regulatory work.

12.2.  While they are primarily for our own staff we share live QRPs with providers, commissioners and others (such as the Department of Health, Monitor and Strategic Health Authority clusters) through a secure section of our website.

12.3.  We flag where we have insufficient data and accept that across the 16 essential standards, there is a wide variation in the volume of information available. It is inherently more difficult to gather information around some outcomes, such as outcome 2 'consent to care and treatment'. This data will organically grow as it is populated as a result of inspection activity.

12.4.  The core philosophy of QRPs is that they will never be 'finished': we are constantly looking for new sources of high quality data or ways to use existing data more innovatively. There will always be new ways to assess risk and we will seek to feed these in as and when they emerge. By way of example we are currently planning to include information from clinical audits and clinical research in the NHS, with a division of some outcomes by clinical specialty.

12.5.  We are developing approaches to deal with the need to adapt to new sources of information and make the most of existing ones. This includes seeking ways to capture more intelligence from CQC staff networks, placing a form on our new website to feed public information into the QRP, and specific projects to develop new indicators relevant to social care.

QRPs in the NHS

12.6.  NHS QRPs contain around 500 items each (over 150,000 pieces of data overall) and we disagree with the Committee that the data is of limited reliability. Data coverage is variable but in areas we have a hugely rich data set. It should be noted that with the benefit of the QRP we are confident that the problems at Mid Staffordshire would have been picked up 18 months earlier than was the case.

12.7.  We mostly rely on third-party data collections, such as those of the Department of Health, the NHS Information Centre and Skills for Care, since we wish to make the best use of information that is already available. It is counterproductive for regulation to unnecessarily increase burdens on providers by partially or wholly duplicating requests for data which already exists in accessible formats.

12.8.  We believe the weakness of Patient Environment Action Team (PEAT) data is overstated in the Committee's report. In the latest round of PEAT inspections, a fifth of all inspections included an external validator and more than three quarters included a user or user representative. PEAT cannot be categorised as self assessment in the pejorative sense.

QRPs in adult social care

12.9.  The amount of data in adult social care QRPs is lower than for the NHS at around 50 items each (over 1 million items of data in total). Data on adult social care has always historically been less readily available, and where it is available often less robust. We acknowledge this disparity and are endeavouring to improve this but it will remain a challenge. Due to the nature of the sector adult social care will never reach parity with the NHS in data terms, which is why we are prioritising other sources of information - from the user voice, and through more frequent inspections.

12.10.  One key project is our close working with ADASS to develop a way to share information via an online portal. This would provide us with more information on where local authorities, that is commissioners of adult social care, have issues with individual care homes. We also have other specific projects to develop new indicators relevant to social care, such as prescription patterns in care homes.

13.  Paragraph 16 - Monitoring front-line staffing ratios in care homes

13.1.  The Committee raised the issue of CQC monitoring front-line staffing ratios in care homes. CQC focuses on the outcomes people receive in the quality of their care, and when relevant looks at the impact of staffing on this. Our recent 'dignity and nutrition' inspection programme demonstrated to us that no hard rule could be arrived at to set the minimum number of staff or a staffing ratio required to provide good quality care to service users. Good care can be delivered in understaffed units, and poor care in well-staffed areas. Setting a minimum staffing level or ratio creates the risk of giving false assurances about the quality of care.

13.2.  We also question the feasibility of keeping track of staffing ratios in care homes. Staffing levels and the skill mix of those staff need to be based on the needs of service users and these can change considerably from day to day and week to week. Staffing ratios are therefore a matter for senior managers within services. Some professional bodies have produced excellent guidance to support senior managers in their staff resource planning but have not felt able to stipulate staffing ratios.

13.3.  What CQC can and does do is to train inspectors to spot the signs of inadequate staffing numbers and / or a poor skill mix. Inspectors can call upon our national professional advisors for advice if they are concerned about these issues and follow up through enforcement action if required.

14.  Paragraph 18 - Maintaining consistency of judgement

14.1.  As outlined in paragraphs 6.1 to 6.4, we are currently publically consulting on a revised and simplified judgement framework and enforcement policy which CQC staff use to guide their decision about taking regulatory action.

14.2.  These improvements will make it easier for our inspectors to make a clear and transparent judgement about compliance and will make it easier for the public to understand the information we publish about providers. For example, we will no longer expect our inspectors to factor in issues such as confidence in the provider to make improvements when coming to their judgement.

14.3.  Our eight-week training and induction programme for new inspectors is designed to equip them with a thorough understanding of how to make judgements about compliance and appropriate enforcement action. This includes spending time shadowing experienced compliance inspectors. All inspectors have access to formal and informal support to aid them in making robust decisions.

14.4.  While consistency across regions and within compliance teams is important, this does not equate to benchmarking. Judgements need to be made based on all available information. While the QRP of a service is one source of intelligence for our inspectors, they will use their local knowledge and networks to add a qualitative perspective to inspections and assessments of compliance.

Report writing and quality assurance

14.5.  The Committee may find it helpful to understand our internal assurance processes for report writing. Checkpoints are in place throughout the inspection process to ensure inspectors consider the integrity of the process. Furthermore, peer review at local level is a central part of quality assurance around regulatory judgements and the production of reports.

14.6.  During the planning phase of a review of compliance (the overall process that usually includes an inspection), inspectors consider all the information CQC has about a service and then decide what specific issues to explore. For example, if the inspection will need to cover detailed aspects of medicines management, the inspector will talk to our pharmacy specialists to request advice and if necessary to attend the inspection.

14.7.  The inspector may also call on a range of clinical specialists for advice. This can include taking specialists along during an inspection (e.g. the use of practising nurses in our 'dignity and nutrition' inspections, or working with midwifery experts as part of our investigation into Barking, Havering and Redbridge NHS Trust).

14.8.  The planning stage is followed by the inspection, which will be unannounced in all bar exceptional cases. During the inspection, the inspector will look for evidence to see whether or not the care service is compliant with CQC's essential standards. The planning stage will usually involve making decisions about which standards are most relevant to the provider. The subsequent inspection will seek to gather evidence most relevant to these.

14.9.  During our inspections we ask people about their experiences of receiving care, talk to carers and family, observe care being delivered, talk to staff, check that the right systems and processes are in place, and look for evidence that suggests care might not be meeting the essential standards. We can follow up an inspection by asking for further evidence, and inspectors can seek expert advice at this stage if needs be.

14.10.  Following the inspection and collection of evidence there are several stages to ensure that the judgement made by the inspector is fair and evidence-based. The inspector who led the inspection produces a draft report, including their judgements. This report is reviewed by another inspector who comments on the judgements, the flow and readability of the report. The amended report is then sent to the inspector's line manager (the compliance manager) for approval. Once approved, the report is sent to the provider for them to comment only on its factual accuracy. The inspector will consider all comments and make changes where appropriate.

14.11.  If an inspection uncovers a 'major concern' with the care provided, an internal CQC management review meeting will be convened. The meeting is chaired by the compliance manager and attended by the inspector and where necessary a legal advisor. The purpose of the meeting is to decide what regulatory or enforcement action will be taken, based on ensuring fairness, consistency and making an evidence based judgement.

14.12.  The final draft of any report is sent to the compliance manager for approval prior to publication. For themed inspections, such as the recent 'dignity and nutrition' inspections, a national quality assurance panel is used.

15.  Paragraphs 19, 20, 21 and 22 - Whistleblowing, and building a culture of raising concerns within provider organisations

15.1.  CQC must ensure our handling of whistleblowing concerns is as robust as possible, and we have improved our processes to do this following Winterbourne View [ANNEX 6].[27]

15.2.  We expect that the organisations we regulate will develop a culture in which it is safe and acceptable for all employees and stakeholders to raise concerns about poor or unacceptable practice and misconduct.

Handling whistleblower information

15.3.  We can confirm that the process for handling 'whistleblowing' information has been reviewed and strengthened since the undercover filming of abuse at Winterbourne View. In June 2011, CQC set up a dedicated team in its National Customer Service Centre to log the details of any whistleblowing calls or correspondence received; this includes allocating the information to an inspector who must then confirm receipt and action resulting from the information. This 'track and chase' process ensures no piece of information is left open.

15.4.  The changes made to the system have been subject to a three-month review which has confirmed that the 'track and chase' process is now embedded. The quality of the process - including the information received and action taken has also been subject to review.

15.5.  There was a significant increase in the amount of this type of information received by CQC after Panorama, but the Committee should be aware that we are assessing whether the increase in quantity was matched by an increase in quality. The findings of these audits will be used to inform future developments in the management of whistleblowing information by CQC.

Whistleblowing and the QRP

15.6.  There is a clear distinction between information which requires immediate action and that which is less immediate but can be used to help spot patterns. Whistleblowing alerts fall into the former category and receive higher precedence in the QRP. They also generate a note for the benefit of compliance inspectors assessing a service at a later date.

Changing organisational cultures across health and social care

15.7.  CQC believes that a system-wide approach to whistleblowing is vital to create a culture that encourages openness within organisations. We firmly believe that the organisations we regulate should develop a culture in which it is safe and acceptable for all employees and stakeholders to raise concerns.

15.8.  Whistleblowing is covered in Outcome 16 of CQC's Essential Standards (on assessing and monitoring the quality of service provision), which prompts registered providers to: "Make sure there is a confidential way for staff to raise concerns about risks to people, poor practice and adverse events. Staff understand the reporting system and feel confident to use it, without fear that they will be treated unfairly as a result of raising a concern.

15.9.  Where we see evidence that this is not the case, we can take action, although interpreting data around this is complex. For example, a decrease in whistleblowing might reflect an improvement in care or a greater openness by management to engage with staff concerns which means whistleblowing is unnecessary; or it could reflect a punitive attitude towards raising concerns that was intimidating staff.

15.10.  As a result of this complexity, CQC has neither the remit nor the capacity to routinely monitor how effectively organisations are developing an open culture. What CQC can do is follow up and take action where we have evidence that an organisation is not supporting staff in the way expected and that this is compromising the quality and safety of care for service users. We have made significant improvements on this front.

15.11.  We also acknowledge it is rightly a key concern of the Committee that we work closely with professional regulators and share concerns wherever appropriate. This is built into our whistleblowing handling procedures and is taken very seriously by the Commission.

15.12.  We agree with the Committee's recommendation about provider Board accountability and the importance of inspecting for proper processes, particularly where there are signs that this may be contributing to poor care. One of CQC's essential standards requires that a provider regularly assess and monitors the quality of the services provided in carrying out the regulated activity. This is clearly a board and senior management responsibility and CQC would expect the provider to demonstrate compliance with the regulation.

16.  Paragraph 23 - Winterbourne View

16.1.  The Committee referred to the abuse at Winterbourne View, shown in the BBC's Panorama programme. As the Committee is no doubt aware, CQC has been open from the outset that its actions in the Winterbourne View case were not acceptable. The decision to rely on the local authority safeguarding process was the wrong one. Our extensive improvements to our handling of whistleblowing data are set out above.

16.2.  CQC has conducted an end to end internal management review of the regulation of Winterbourne View hospital from the time of its registration to the time of its closure. The review will be CQC's formal contribution to the Serious Case Review commissioned by South Gloucestershire Safeguarding Adults Team, which is currently underway.

16.3.  Immediately after the broadcast we wrote to the Minister of State for Care Services, Paul Burstow MP, with a proposal for a programme of risk-based and random unannounced inspections of the 150 hospitals providing care for people with learning disabilities across England. This is now underway, supported by an advisory group and experts by experience.

17.  Paragraph 24 - Healthwatch

17.1.  We note the Committee's comments with regard to HealthWatch. This is a matter for Parliament to decide, although CQC will of course work with HealthWatch England to explore matters of concern about poor care wherever appropriate. We have work underway with LINks to manage their relationship with CQC while they transition to become local HealthWatch organisations. This is complementary to CQC's extensive programme of engagement with the broader range of user and carer voices that we draw on to make assessments of risk in care services across England.

The registration process

18.  Paragraphs 25, 26, 27 and 29 - Improving providers' experience of registration

18.1.  We continue to work hard to transform and improve the ways providers communicate with us. This spans the registration process, our National Customer Service Centre and our Online Services project for providers, which is currently in development.

18.2.  From 1 July 2011 we streamlined registration to provide a better customer experience. This included improved application forms with clearer guidance and asking for references only on a 'need to know' basis.

18.3.  We are also currently considering our long term approach to registration and plan to engage providers and stakeholders in this work. The aim is to enable us to better flex our model to individual circumstances. We need to ensure we maintain the right balance of ensuring registration is a robust process that acts as a quality check to market entry but is not unnecessarily burdensome or time consuming.

Case study: Southern Cross

18.4.  The recent situation with Southern Cross provided an opportunity to review our processes to ensure that our focus was on the essential requirements to safeguard users and comply with legislation. An example of this review's impact is how we have refined CQC's requirements around registered managers to improve the process.

18.5.  The transfer of Southern Cross homes to a range of new providers has taken place smoothly with a minimum of disruption for those using services. In order to deliver an effective transfer, we focused on the legislative and registration requirements for managers. In doing so we considered that managers should be able to maintain their registration when they would be remaining at the same location and providing the same regulated activities but employed by a new provider.

18.6.  In making this change we used information from our inspection activity to inform our knowledge and judgements about individual registered managers. This means in most cases managers maintained their registration while the registration of the service itself changed. We are content this continued to safeguard users, complied with the legislation and removed unnecessary burden for providers.

18.7.  Greater reliance was placed on what we know of these managers from our review of compliance of the services they manage. The changes made in response to applications in relation to Southern Cross are being incorporated into our usual registration activity.

National Customer Service Centre

18.8.  We have asked providers their views on their interactions with CQC, especially with our National Customer Service Centre. While aspects of the feedback have been positive we are aware also of areas where we need to improve and have started acting to correct these issues. A summary of the latest survey of providers suggests that we are moving firmly in the right direction [ANNEX 7].[28] We undertake this survey quarterly to make sure we are aware of what providers think about our service.

18.9.  We worked to ensure a marked upturn in the volumes of registration applications we are able to process in an effort to minimise the chance of backlogs developing in future. By way of example, we reduced the time taken to process registration applications meaning that by April 2011 we hit a record of 1,700 applications processed in one week, at the same time as answering over 90% of calls within 20 seconds.

Online Services

18.10.  We will start a pilot of the first release of Online Services in December 2011 - for example, allowing providers to submit notifications online rather than in written form. This both reduces the number of transactions and improves the delivery of information to the right place. We envisage that these online account management tools will become the main way that providers interact with the Commission on a day to day basis. This pilot will be used to evaluate the effectiveness of the services.

18.11.  If the pilot is successful, by April 2012 we expect that over 95% of notifications which are submitted to us could begin to move online. We anticipate this will improve the provider experience of sending us information and also improve our data quality.

19.  Paragraph 28 - Improving transitional registration for primary medical services (including GP practices)

Primary medical services (including GPs)

19.1.  We are now using the delay of the transitional registration of primary medical services to review and improve the registration process. This will include developing an online application and tracking service, improving our guidance, and working closely with stakeholders to ensure the registration process is fit for the sector. The streamlining of the process is already underway; including reducing the occasions where we require a CQC-countersigned enhanced Criminal Records Bureau check.

19.2.  We have held an early focus group with GPs and practice managers to examine the proposed approach to application forms using our new online services for providers. Further focus groups and pilots will test the usability of this approach and the final online forms.

19.3.  A primary medical services advisory group has been set up with key stakeholders, including the General Medical Council and British Medical Association, allowing them to take part in the development of the transitional registration process. We are also directly engaged with providers through our online Provider Reference Group which regularly hosts live web chats and examines our documentation. Membership of this is open to any provider.

Provision of information to the public

20.  Paragraph 30 - Information for the public

20.1.  CQC wants to put as much information into the public domain as possible to help people make informed judgements about their care. The main way we do this is through our website, the new version of which launched in October 2011 and which is designed to give the public essential information to help inform their choices about health and social care.

20.2.  Every service registered with CQC has a 'provider profile' on the site where services users, their carers and members of the public can see a clear and up to date summary of our judgement of the service. More detailed information from our reports about what our inspectors found and what people using services told them is only a click away. Where we are conducting a review of a service this is highlighted on the provider profile. Our new reports are added to the website on a weekly basis.

20.3.  To help us capture as much information as possible about the services we regulate, each provider profile has a tab where people who use services can share their experience with us. This feedback is triaged and then fed into the QRP for the service where our inspectors can pick it up.

20.4.  We acknowledge that there were delays to the launch of the website for which we apologise and are due to a number of technical and resource factors:

20.4.1.  Recruitment - in her letter to Una O'Brien at the Department of Health on 22 November 2010, Jo Williams raised concerns about recruitment to business critical posts in the website team, which at that point had a vacancy rate of 50 per cent. It was highlighted that this team was critical to fulfilling the legislative requirement of making information available and accessible to people who commission, choose and use services.

20.4.2.  Complexity of task - turning a highly complex data set into meaningful information that was also easily digestible for a public audience required a considerable amount of work.

20.4.3.  Consultation and testing - we wanted to make sure we got the website right, making it a valuable resource for service users, their carers and the public. This involved a lot of iterative testing, the full timescales for which were difficult to accurately map in advance.

20.4.4.  Technical challenges - the alignment of internal systems, processes and data quality required overcoming a large number of time consuming challenges to support our new digital approach. The work done sets us in good stead for our future digital platform.

20.5.  It has taken longer than we would have liked to launch this site, but our view is that the delays have been justified by the final result. In building the site, CQC had to work to transform highly complex data into meaningful information, easily digestible for the public. The Commission carried out extensive consultation and testing with the public and providers to build a site that works for our many audiences. Internal systems had to be adapted to ensure that the publication of clear, timely information about our compliance monitoring was embedded in our ways of working.

20.6.  The site will continue to develop and improve in the short- and medium-term. The increase in CQC's inspection activity will see us build a better and richer picture of the quality of care across England over time, and the quality of information on the website will improve in line with this.

21.  Paragraph 31 - Adult Social Care Excellence Award

21.1  The Department of Health has confirmed that CQC will not be proceeding with the adult social care excellence award, following the feedback received during our recent consultation exercise.

21.2  The social care white paper, to be published next year, will look at how to drive quality improvement in social care and the role CQC might play in this.

22   Annex 1 - Letter from Dame Jo Williams to Minister of State for Health Services, 31 October 2011 (not printed here) Back

23   Annex 2 - Reviews of compliance (including site visits) completed by CQC from 1 April 2010 to September 2011 (not printed here) Back

24   Annex 3 - Letter from Dame Jo Williams to Permanent Secretary, Department of Health, 28 March 2011 (not printed here) Back

25   Annex 4 - CQC consultation on judgement framework and enforcement policy (not printed here) Back

26   Annex 5 - CQC performance scorecard (not printed here) Back

27   Annex 6 - Updated CQC whistleblowing procedures (not printed here) Back

28   Annex 7 - Provider sentiment tracking (not printed here) Back

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Prepared 7 March 2012