Conclusions and recommendations
1. The Department is ultimately responsible
for the effective regulation of health and adult social care but
has not had a grip on what the Commission has been doing.
It is clear that the Commission has been struggling for some time,
but only now has the Department started to take action. During
the hearing the Department's Accounting Officer set out five areas
where she wants to see improvements. The Department should turn
these areas into an action plan which sets out in detail exactly
what needs to be done to secure the changes required. The Department
should report back to us by the end of April 2012 on when we can
expect to see progress against each of the five areas.
2. The Commission has been poorly governed
and led. The Commission has failed to
strike the right balance between registration and inspection.
A Board member, Commission staff and representatives of the health
and adult social care sectors have raised serious concerns about
the Commission's leadership, governance and culture. The Commission
is regarded as overly focused on reputation management and has
included gagging clauses in its severance deals with staff. Such
clauses discourage people from speaking out and making public
information that would help drive improvement and hold the Commission
to account. The errors in the Commission's annual report to Parliament
also raise questions about the effectiveness of governance and
internal control. The Department should carry out a fundamental
review of the adequacy of the Commission's current governance
and leadership, take action to strengthen these areas and hold
the Commission and its senior management to account.
3. The Commission's role is unclear and it
does not measure the quality or impact of its own work.
The Commission's objective, as set out in legislation, is to 'protect
and promote the health, safety and welfare of people who use health
and social care services' but it has not defined what success
in delivering this objective would look like. It is unclear to
what extent the Commission's role involves improvement beyond
the essential basic standards of quality and safety. Although
the Commission is a Quality Commission it only measures itself
against quantitative, activity-based performance measures, with
no measures of quality or impact. The Commission, working with
the Department, should set out clearly what it is seeking to achieve
and develop measures of quality and impact which can be used to
assess its effectiveness.
4. The information provided to the public
on the quality of care is inadequate and does not engender confidence
in the care system. The Commission does
not collate data on enforcement action, and does not present its
assessments in a way that gives the public a clear picture of
the state of care available. Residential care homes are no longer
awarded star ratings, which previously helped the public to differentiate
between providers. The Commission should collect and publish data
on enforcement, together with information on the extent to which
providers in particular areas are meeting the essential basic
standards to allow the public to get a national, regional or local
picture of the state of care. In addition, the Department should
address the gap left by the removal of star ratings.
5. The registration of GP practices must involve
a meaningful assessment of compliance with the essential standards
of quality and safety. The proposed process
will involve GP practices declaring areas where they are not compliant,
and the Commission told us that it will seek to draw on other
sources of information to indicate which practices give rise for
concern. We are not convinced that this approach will work in
practice, particularly given the number of GP practices to be
registered, and the Commission risks becoming simply a postbox.
The Commission should review and set out how it will make sure
that the assessment of GP practices is meaningful. It should develop
clear criteria to use to judge when it needs to undertake further
investigations before a practice can be registered.
6. There are inconsistencies in the judgements
of individual inspectors and in the Commission's approach to enforcement.
The Commission's own internal auditors found variations in how
inspectors assess risk and we received evidence that there is
insufficient focus on both the quality and consistency of inspectors'
work. In addition, the approach to enforcement is variable, with
action more likely to be taken against care homes than hospitals.
The Commission should provide training and guidance to inspectors
that specifically addresses the risk of inconsistent judgements
in inspections and enforcement, and should use performance data
to monitor trends and identify areas of concern.
7. The Commission must strengthen its whistleblowing
arrangements. Whistleblowing information
from staff and the public should be a key source of intelligence
about the quality of care, and the number of whistleblowers has
increased dramatically since the Winterbourne View case came to
light in May 2011. However, the Commission expects callers to
use its general enquiry line, which may discourage whistleblowers
and not give them the specialist support they require. The Commission
should re-establish a dedicated whistleblowing line, operated
by specialist staff, and publicise it widely.
8. The Commission should not take on the functions
of the Human Fertilisation and Embryology Authority at this time.
The Department is proposing to transfer
to the Commission the functions of other organisations, including
the Human Fertilisation and Embryology Authority, which regulates
IVF services. In our view, the Commission does not have the capacity
to take on oversight of such a complex area, and the change would
undermine its ability to focus on the improvements it needs to
make in relation to its existing regulatory functions.
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