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
| 
