2012 accountability hearing with the Care Quality Commission - Health Committee Contents

3  Purpose of the CQC

Regulatory approach

15. The question of the CQC's core purpose has not been resolved since the regulator was established in 2008. Memoranda we received from the NHS Confederation and the Foundation Trust Network addressed this matter, but there was no consensus on what the fundamental role of the regulator should be. The NHS Confederation said that:

The Government should amend the CQC's statutory duties to reflect that its primary role is to assure essential standards, and that it has a limited role to play in driving improvements in the quality of care.[12]

The NHS Confederation added that the CQC's role in driving up quality is "through effective regulation and registration against its essential standards".[13] This view contrasts with that of the Foundation Trust Network, whose evidence agrees that the CQC should concentrate on essential standards but adds that CQC should be a "thought leader in the health system, analysing the data it holds to unpack the drivers behind standards and inform best practice."[14]

16. The Department of Health's performance and capability review of the CQC recommended that "CQC's strategy needs to be revised, explaining what role and impact its regulatory action is intended to have in specific sectors over time."[15] In its memoranda to the committee the CQC says that its purpose is to "drive improvements in the quality of care",[16] but in itself, we were not satisfied that this would address the serious criticism contained in the performance and capability review that "strategic prioritisation of essential standards is not understood at all levels within the Commission."[17]

17. In failing to understand its essential purpose, the CQC risks undermining its own attempts to realign its strategic priorities following a period of sustained criticism and review. In evidence the CQC's new Chief Executive David Behan told us that the CQC's "unique contribution [...] is that we measure the national standards of quality and safety."[18]

18. The CQC must work closely with other regulators and commissioners working in health and social care. There is an urgent need for all these organisations to define their role and purpose in order to achieve organisational focus and to avoid duplication.

19. We agree that the CQC's fundamental purpose is to ensure that health and social care providers meet those essential standards which ensure patient safety. The Committee remains concerned that the role and duties of the CQC are not sufficiently clear. Responsibility for patient safety lies at the root of high quality patient care, but is in danger of being obscured by other competing priorities. This is a particular concern given that the Government has abolished the National Patient Safety Agency and absorbed it in to the NHS Commissioning Board. We recommend that the Secretary of State should urgently work with the statutory regulators and commissioners of health and social care in order to simplify and clarify their respective roles. We further recommend that the Secretary of State should reconsider whether prime responsibility for patient safety should reside with the CQC.

Essential standards and raising the bar

20. Significant concern exists that the CQC's essential standards do not guarantee acceptable levels of care in residential social care. The Relatives and Residents Association say in their memorandum to the Committee that "the experience of [...] poor quality care is not exceptional"[19] and they argue convincingly that levels of risk and the degree of safeguarding necessary in residential care are inherently greater than other care settings because of the simple fact that a care home doubles as a person's home.

21. In her evidence, Jo Williams told us that the CQC was:

increasingly focusing on what has been the experience of people living in that environment: how have they experienced it, are they happy with the way in which they are treated as an individual and the services they all receive.[20]

This is welcome if the CQC can demonstrate that a renewed focus improves the process of registration and inspection to address the concerns of relatives and residents.

22. In relation to social care there is too often a disconnect between the essential standards measured by the CQC and the experiences of residents in social care. In too many cases residential care homes which meet the CQC's essential standards are regarded as unsatisfactory by carers, relatives and residents. In reviewing their regulatory model the CQC must ensure that the 'essential' standards they enforce align with the expectations and experiences of patients, residents and relatives. We look to the new management team to work from the principle of 'first do no harm' and focus on this core issue with a much greater sense of urgency.

23. Dame Jo told us that the CQC's objective is to turn today's quality standards into tomorrow's essential standards. The CQC must recognise that the public has little confidence that the essential standards the CQC enforces guarantee an acceptable standard of care. On too many occasions providers who meet these standards have subsequently been found to be delivering severely substandard care.

24. The first priority for the CQC is to apply its existing standards consistently and effectively. When the CQC is able to command public confidence that it has achieved this objective, the Committee will seek a progress report on this issue and on plans for the progressive raising of these standards in line with public expectation.

Purpose of inspection

25. The purpose of CQC inspections is to establish whether the quality of care provided in an organisation meets acceptable quality standards. CQC reports are relied upon both by statutory commissioners in the NHS and social services departments, and by individuals and families making choices about their own care - whether it is self-funded or funded by the taxpayer. In recent years there have been too many examples for comfort of care standards falling below acceptable levels, sometimes by an extraordinarily wide margin. The fact that this has happened in care settings which have been registered as satisfactory by the CQC only serves to emphasise the importance of developing more effective processes.

26. It is, however, important to be clear where primary responsibility lies. When care standards fail, it is the care provider that is responsible.

27. Furthermore, when commissioners have commissioned care from a provider who fails to deliver service of an acceptable quality, the commissioners should expect to face questions about the effectiveness of their commissioning processes. Commissioners exist to secure good value for the taxpayer and high quality for patients and residents; while they are not themselves inspectors, commissioners should be expected to provide themselves with sufficient information about the cost and quality of care provided to allow themselves to make properly informed decisions. Failures to do so—of which there have been too many examples—constitute culpable failures by commissioners to act with due diligence. Commissioners ought to be able to turn to the CQC for evidence of the quality of care provided. The CQC Board and management need to show that they use the resources at their disposal effectively to deliver the necessary assurance to commissioners, patients and their families. The record shows that it has not so far been able to provide such assurance.

28. We welcome the fact that the CQC has undertaken a consultation with its stakeholders about the scope and purpose of the organisation. In view of its unhappy history, we believe that it needs to do more. We believe it should consult with stakeholders about effective means as well as desirable ends. We therefore recommend that before the accountability hearing in 2013 the CQC should undertake an open consultation designed to develop a clearer understanding of effective regulatory method.

29. There have been too many reports of CQC inspections which focus on easily measurable inputs, rather than the essential quality of care provided. The organisation has sometimes seemed to be an illustration of the dangers of the principle that 'what gets measured gets managed'.

30. In particular we would encourage the CQC to require its inspectors to ask themselves about the culture of care within an organisation. There is abundant evidence that organisations with closed and autocratic cultures do not deliver consistently high quality care. Similarly the professional obligation of clinical staff to accept responsibility not just for the care they provide themselves, but for the context in which it is provided, is inconsistent with an organisational culture which discourages dialogue and challenge.

31. We recommend that, as part of a general consultation about regulatory method, CQC should consult in particular on how to assess the culture of a care provider - in order to satisfy itself that a healthy open culture prevails amongst professional staff.

12   Ev 37 Back

13   Ev 38 Back

14   Ev 33 Back

15   Department of Health, Performance and Capability Review: Care Quality Commission, 2012, p 7 Back

16   Ev 43 Back

17   CQC Performance and Capability Review, p 21 Back

18   Q 139 Back

19   Ev 30 Back

20   Q 20 Back

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Prepared 9 January 2013