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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