Appendix 6: Care Quality Commission's
The balance between registration and compliance
1. Paragraph 1 - Prioritisation during
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
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
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
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
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].
2. Paragraphs 2 and 7 - Piloting transitional
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.
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
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
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
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
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
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]. 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
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
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
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
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].
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].
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
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
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
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
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.
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
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
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
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
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 -
220.127.116.11. 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:
18.104.22.168. "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
22.214.171.124. 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
10.1. CQC has made significant progress in developing
effective performance indicators and enclosed is the latest performance
scorecard [ANNEX 5].
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
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
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
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
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
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].
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
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
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
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]. 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.
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
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
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
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
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
Annex 2 - Reviews of compliance (including site visits) completed
by CQC from 1 April 2010 to September 2011 (not printed here) Back
Annex 3 - Letter from Dame Jo Williams to Permanent Secretary,
Department of Health, 28 March 2011 (not printed here) Back
Annex 4 - CQC consultation on judgement framework and enforcement
policy (not printed here) Back
Annex 5 - CQC performance scorecard (not printed here) Back
Annex 6 - Updated CQC whistleblowing procedures (not printed here) Back
Annex 7 - Provider sentiment tracking (not printed here) Back