The Care Quality Commission: Regulating the quality and safety of health and adult social care - Public Accounts Committee Contents

2  The operations of the Care Quality Commission

11. The Commission plays a vital role in protecting the users of health and adult social care services by deterring poor quality or unsafe care, detecting where it does exist, and taking action to ensure providers comply with the essential standards. The way the Commission operates has a significant impact on the quality and safety of care, and on public confidence in the health and social care system.[20]

12. The National Audit Office reported that, in November 2011, the Commission had major concerns about 407 providers, 94% of whom were adult social care providers. This paints a worrying picture for the users of the services in question.[21] The Commission confirmed that each of the 407 cases would be reviewed on a regular basis and progress monitored. If necessary, additional inspections or enforcement action would be taken.[22]

13. In December 2009 the Commission reorganised its staff into regional teams and disbanded its national investigations team.[23] Since then it has begun to undertake thematic reviews of particular aspects of care covering a sample of providers. For example, the dignity and nutrition inspections carried out between March and June 2011 identified concerns in 55 of the 100 NHS hospitals inspected. The Commission has since re-visited the hospitals concerned.[24]

14. The remaining large scale registration exercise is the registration of GP practices. The Commission will have to register some 10,000 GP practices between September 2012 and April 2013.[25] Previous registrations did not run smoothly and the Commission has streamlined its approach for GP practices. The new process will involve each GP practice completing a simplified online application form, which will require them to declare if they are fully compliant with the essential standards or to highlight areas of non-compliance.[26]

15. The Commission has piloted the streamlined approach and 25% of GP practices declared that they were not compliant with the essential standards.[27] The Commission does not expect it will need to follow up all such cases, especially where there is an action plan in place to mitigate the risks. However, a proportion will need to be looked at in greater detail, together with GP practices where the Commission has concerns based on information from other sources. The Commission will draw on information from primary care trusts and the General Medical Council to inform its judgement as to whether a particular GP practice should be registered, and will, if necessary, carry out an inspection.[28]

16. Registration is important as it indicates that the Commission is satisfied that a GP practice is complying with the essential standards and, without it, practices will not be subject to the Commission's enforcement powers.[29] We are concerned, however, that the Commission will simply be a 'postbox' for self-certified applications and that the process will not be sufficiently robust to give the public meaningful assurance that registered GP practices are meeting the essential standards.[30]

17. When the Commission has had to register large numbers of providers in the past, the number of inspections undertaken dropped dramatically. Inspections are now increasing, however, and the Department assured us that inspectors will not be diverted to help with the registration of GP practices.[31]

18. There is evidence of inconsistency in how inspectors carry out their work. The Commission's own internal auditors reported in March 2011 that differences in approach were leading to inconsistencies within and between regions.[32] We received evidence that there is no robust assurance system to ensure that inspectors' judgments are consistent, and that the Commission's focus is on activity levels rather than the quality of inspectors' work.[33] The Commission referred to the quality assurance systems it has in place and the role of compliance managers in overseeing inspectors and securing consistency.[34]

19. Each inspector has a large and varied portfolio, covering, for example, hospitals, care homes and dentists. We received evidence that inspectors have not been given enough training and support to understand fully what constitutes good quality care in sectors where they have no experience.[35] The Commission told us that inspectors are expected to be experts in regulatory, not clinical, standards, and are supported by practitioners with up-to-date clinical expertise. For example, when the Commission starts to inspect GP practices, inspectors will be accompanied by GPs to help establish the things they should be looking for.[36]

20. The Commission has a range of enforcement powers to deploy when it judges that a provider is failing to meet the essential standards. For example, it can restrict the number of beds in a care home or hospital or the type of activity that can be undertaken at a particular location. Ultimately, it can prosecute a provider, although this power has never been used.[37]

21. We heard evidence about inconsistencies in the Commission's approach to enforcement. Specifically that enforcement action is not taken as quickly in hospitals as it is in care homes, and that the sanctions applied in the case of NHS providers are more lenient.[38] The Commission told us that it may use its powers differently because of local circumstances. In making judgments about enforcement action it has a legal obligation to be proportionate and to consider the impact of its decisions on the provider and the services available to the wider community. It had begun to take action against NHS providers, and agreed that it had the option of closing individual wards rather than whole hospitals.[39]

22. The Commission collects only limited data on enforcement.[40] It is therefore not possible for the public, or the Commission's own Board, to build a national picture of enforcement activity or to see where the Commission is having an impact. This information is fundamental to maintaining public confidence.[41] More generally, data on compliance with the essential standards is not presented in a way that allows comparisons between providers and there is no comprehensive view of the overall state of care.[42] The Commission said that, starting with adult social care from April 2012, it would have a specialist team which would produce a 'market overview' of trends in non-compliance.[43]

23. In the past, residential care homes were awarded star ratings, which helped the public to differentiate between providers and make informed choices. Ministers decided in June 2010 to stop the star ratings system. The Commission assesses providers simply as compliant or non-compliant with the essential standards, and no organisation provides information on the quality of care beyond this.[44] The Department agreed that the public wanted to be able to differentiate between care providers and that there was currently an information gap. It does not consider it is the Commission's role to fill the gap, and plans to address the issue in the Social Care White Paper.[45]

24. Whistleblowers should be a key source of intelligence about the quality of care. The Winterbourne View case highlighted major problems in the way the Commission handled whistleblowing information.[46] The Commission was contacted on more than one occasion by a whistleblower with information about what was happening at the home and, although it passed the information on to the local authority concerned, it did not follow up to check what action had been taken. It took a BBC Panorama programme to expose the abuse of patients. [47]

25. Since the Panorama programme in May 2011, the Commission has received approximately 2,500 whistleblowing calls, a dramatic increase on the 200 calls received in the course of a year prior to the programme.[48] However, the Commission scrapped the dedicated whistleblowing helpline that the Healthcare Commission had used and whistleblowers are expected to use the general helpline number.[49] The Commission stressed, however, that its arrangements had improved since Winterbourne View. It now has a team of six people to make sure that every whistleblowing call is followed up by an inspector.

20   Qq 31, 82, 165, C&AG's para 1.5 Back

21   Q 38 Back

22   Ev.43  Back

23   Q 86 Back

24   Qq 26, 27 Back

25   C&AG's Report, Figures 3 & 12 Back

26   Q 68 Back

27   Ev.40 Back

28   Qq 70-74 Back

29   Qq 61-62, Ev. 39 Back

30   Qq 157, 161 Back

31   Qq 80-81, C&AG's Report, para 4.20 Back

32   Qq 139, 212, C&AG's Report, para 4.13 Back

33   Q 208, Ev.37, C&AG's Report, para 4.13 Back

34   Ev.44 Back

35   Qq 166, 193, Ev.38  Back

36   Qq 194-195 Back

37   Q 35, C&AG's Report, para 4.25 - 4.27, Figure 16 Back

38   Qq 25, 29 Back

39   Qq 30, 127-128 Back

40   C&AG's Report, para 1.17 Back

41   Q 35 Back

42   Q 228 Back

43   Ev.43 Back

44   C&AG's Report, para 1.13 Back

45   Q 202 Back

46   C&AG's Report, para 4.8 Back

47   C&AG's Report, Appendix three Back

48   Q 100 Back

49   Qq 95-96 Back

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Prepared 30 March 2012