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Purpose of the CQC
The CQC's new approach to registration and inspection was established in their revised strategy published in April 2013 and consulted on by the CQC in July 2013. The CQC said that it now had a clear purpose - "to make sure health and social care services provide people with safe, effective, compassionate, high-quality care and to encourage care services to improve." Allied to this is the CQC's role which they said is to:
monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety, and to publish what we find, including performance ratings to help people choose care.
Lack of clarity and direction has previously undermined the CQC's attempts to establish itself as an authoritative regulator. In our report following the 2012 accountability hearing, the Committee found that CQC had failed to establish its core purpose or describe what it intended to achieve through its regulatory activity.
The committee welcomes the fact that the CQC has now set out its objectives in clear terms. This in turn has helped to provide clarity to a regulatory landscape the committee described in 2012 as "cluttered and opaque" . The Committee believes that the CQC is now ready to undertake a programme of substantial reform to develop and improve its regulatory functions.
Chief Inspectors
The CQC has appointed three Chief Inspectors to oversee the inspection of Hospitals, Primary and Integrated Care, and Adult Social Care. The Chief Inspectors are tasked with leading specialist inspection teams, applying the CQC's revised model of inspection and developing a rating system for providers.
It has been proposed by the Department of Health that the Chief Inspectors be established as permanent statutory positions rather than simply appointments within the CQC. The CQC's Chief Executive, David Behan, explained, however, that this would not invest them with additional powers and that the Chief Inspectors will remain accountable to the CQC's Chief Executive and Board.
The committee will continue to follow the evolving relationship between the Chief Inspectors and the Chief Executive of the CQC regarding policy and operational decisions. We believe that as the methodology for registration, inspection and rating of health, social care and primary care advances over time the Chief Executive, acting on the authority of the Board, will play an important role in coordinating the approaches of the Chief Inspectors.
Definition of Standards
The CQC has announced that it will now assess the quality of hospitals against a range of standards which are divided in to three groups: Fundamentals of Care, Expected Standards and High-quality Care. The CQC, in conjunction with the Department of Health, plans to alter its regulations so that it can immediately initiate a prosecution following breaches of fundamental standards without first being required to issue a warning notice. The Committee believes that in most cases the ability to close a unit or a department by cancelling a provider's registration and withdrawing their licence is of more immediate significance to patient care than prosecution. The Government and the CQC should therefore keep these powers under review to ensure the CQC enjoys a sufficient range of sanctions to levy against failing providers.
Expected Standards
The standards expected of providers are to be directly linked to five key questions which have been established by the CQC. The questions ask of providers:
i. Are they safe?
ii. Are they effective?
iii. Are they caring?
iv. Are they responsive to people's needs?
v. Are they well led?
The Committee believes that translating standards into regulations is the key challenge for the Department of Health and the CQC as the registration requirements for providers underpin the rest of the surveillance, inspection and rating system. We believe the new system could simplify the regulatory process but the new standards must be meaningful in relation to the everyday experiences of patients. Taking immediate and firm action against those who breach these standards will enhance the credibility of the system.
Implementation of reform
The evidence provided to the committee shows that the CQC has an ambitious timetable for reform of registration and inspection. We note, however, that some witnesses have expressed concern that the new model for registration and inspection will focus too closely on hospitals, primary care and social care at the expense of community, ambulance and mental health services. In addition the CQC has published substantially more information on its programme for hospitals than it has for general practice and adult social care.
The committee believes that the CQC is right to establish clear priorities but at our next accountability hearing we expect the CQC to present clear details of how effective registration, surveillance and inspection will be extended beyond hospitals.
Surveillance
The CQC plans that future inspections will be informed, and on occasion prompted, by an ongoing surveillance process. The CQC has said that they will not draw definitive conclusions from the indicators they use to asses risk, but they will be used as "smoke detectors which will start to sound if a hospital is outside the expected range of performance or is showing declining performance over time for one or more indicators." If it is to build public confidence in a risk-based regulatory system, the CQC will require early identification of developing problems. The surveillance system must identify problems and trigger inspections before they become widely publicised by the media, patient groups or local representatives.
Staffing
The CQC plans to apply its methodology so that it can provide an accurate assessment not only of the theoretical establishment of a provider but of the actual number of staff working. The Committee welcomes the significance the CQC attached to staffing in their evidence. We believe that information gathered from the CQC's surveillance model which suggests that staffing levels are inadequate should be a trigger for inspection. The Committee is satisfied by the CQC's statement that staffing levels will be attached to the fundamental standards of care which providers must meet or face immediate sanction.
Patient safety incidents
In the report of the Committee's last accountability hearing with the CQC we questioned the rationale for transferring the functions of the National Patient Safety Agency to NHS England. The committee recommended that "the Secretary of State should reconsider whether prime responsibility for patient safety should reside with the CQC." The committee is pleased that the CQC is, in principle, willing to take on the responsibilities that once resided with the NPSA. It is illogical to split different aspects of patient safety between NHS England and the CQC and this reform would simplify the regulatory environment.
Financial monitoring of social care
The Care Bill currently before Parliament proposes to give the CQC specific powers to monitor the financial strength of approximately 50 to 60 care providers whose financial collapse could trigger a local crisis in the delivery of care. The CQC said that in order to fulfil their obligations the CQC does not currently have the financial skills that are required to achieve this and will need to buy in skills from external organisations.
The Committee recommends that the Government should reconsider its decision to allocate this responsibility to CQC and that it should ask Monitor to undertake this role. This would facilitate the reduction of boundaries between healthcare and social care and would maintain the existing distinction of principle between the CQC, which focuses on care quality, and Monitor, which focuses on financial performance.
Fit and Proper Persons test
Part of the revised registration process arises from the Government's desire for the CQC to operate a fit and proper persons test so that named directors or leaders of organisations can be held to account. However, it was revealed in evidence that the CQC will not apply the test to Chairs of NHS Trusts and NHS Foundation Trusts. The Committee does not believe that patients and the public will understand or accept this exclusion.
Inspections
The process of inspection is changing significantly as the CQC adopts a model of differentiated, in-depth inspection. The new model abandons generalist, generic inspections and from 2013-14 the CQC intends only to operate "teams of inspectors who specialise in particular types of care". The CQC told the Committee that problems identified by surveillance will be a trigger for inspection but it will not be possible to pick up every single error or failure.
The Committee accepts this and reiterates that primary responsibility for the quality of care delivered to patients rests unambiguously on the staff and management of care providers. The proposed inspection system represents a comprehensive improvement but the CQC must ensure that inspection is accurately targeted at risk. David Prior, Chair of the CQC, recognised that surveillance will not identify specific risks in outstanding hospitals and that some high risk services will require frequent inspection even if they are regularly classified as 'outstanding'.
Assessing the culture of providers
In the report of the Committee's last accountability hearing, we recommended that CQC should consult on how to assess the culture of a care provider. The CQC's fifth question for inspection - is a provider well led? - addresses this as does the presence of the Chief Inspectors who have been tasked with making such an assessment. The Committee welcomes this development and urges the assessment to be developed so that it does not simply measure Board level governance practices, but properly assesses whether a culture of openness and challenge exists amongst front-line staff.
CQC internal restructuring
In oral evidence David Behan provided an overview of how the CQC workforce will be restructured, telling the Committee that the role of every member of staff is likely to change. This will include creating specialist inspection teams and recruiting additional inspectors, a process which could take up to 18 months.
The CQC is planning to recruit an additional 150 inspectors to increase their establishment from 950 to 1,100. This process is vital to improving the effectiveness of the organisation; we therefore recommend that the CQC set an early target date for the achievement of this increase and provide regular reports to Parliament on progress towards delivery of the objective.
Beyond the inspection teams the CQC has said that they will need a total complement of 2,700 staff to fulfil their obligations. £20 million has already been allocated to support recruitment and retraining and a further £29 million will be used to support the new inspection process. The CQC has, however, yet to establish how this allocation will be used. The Committee recommends that the CQC Board reach early decisions about the allocation of this additional resource and that it should make its decision public.
Ratings
The CQC proposes a rating system for NHS hospitals comprising four separate classifications: Inadequate, Requires improvement, Good, and Outstanding. The same system will be applied to general practice and social care and all providers will be awarded a rating. The Committee welcomes this proposal; the CQC must quickly establish public understanding of, and confidence in, the new system.
Providing information to the public
Behind the headline rating attached to a hospital, care home or GP surgery, there will be a detailed inspection report. In our last report the Committee recommended that the CQC explore how they "can more effectively communicate with residents of care homes and their relatives about the outcomes of inspections." The CQC said that they are considering whether they should write to residents of care homes informing them of the outcome of inspections. The Committee is disappointed that the CQC is still "going to consider" this issue. It regards early action as fundamental to delivery of the core purpose of the CQC. It recommends that this recommendation of last year's report is adopted and implemented by the CQC no later than 30 June 2014.
Internal culture at the CQC
At previous accountability hearings we have taken evidence on the workplace culture within the CQC. In the committee's last report we outlined worrying practices related to the excessive workloads of inspectors. The CQC has accepted that there was a chronic problem with the CQC's workplace culture and they have developed new mechanisms for staff to raise concerns about bullying and other workplace problems. The Committee welcomes the CQC management's commitment to this process of culture change within the organisation.
Concern has been expressed to the Committee about the impact of individual workload on the culture of the organisation. Management of workload is an important part of business planning. At our next accountability hearing the Committee will seek assurances that workforce planning associated with the new regulatory model has not repeated the mistakes of the past.
Funding
The CQC's budget has risen rapidly in the last year and is likely to rise further. The CQC confirmed that it is no longer their objective to phase out grant-in-aid funding. This is because only a substantial increase in fees would allow for the elimination of grant-in-aid. The Committee welcomes the commitment that has been given to ensure adequate funding for the CQC. In the longer term, however, the independence of the CQC will be substantially reinforced when arrangements are in place to ensure that the cost of regulation is met by the registrant community.
The case of Anna Jefferson
On 3 October 2013 it was announced that the CQC's Head of Media, Anna Jefferson had been cleared of any wrongdoing by an internal inquiry examining allegations that a critical internal report related to University Hospitals of Morecambe Bay NHS Foundation Trust had been suppressed by senior CQC staff. The Grant Thornton report alleged that Ms Jefferson had been involved with the decision to cover up the report.
The Committee regards it as regrettable that the Grant Thornton report appeared to lend weight to the allegations made against Ms Jefferson. The Committee does not, however, believe that this case undermines the broad conclusions made by the Grant Thornton report in relation to serious historic failures made by the CQC.
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