3 Regulatory reforms
Chief Inspectors
15. The CQC has appointed three Chief Inspectors
to oversee the inspection of Hospitals (Professor Sir Mike Richards),
Primary and Integrated Care (Professor Steve Field) and Adult
Social Care (Andrea Sutcliffe). Professor Sir Mike Richards took
up his role in July 2013 and therefore the CQC's work to develop
their renewed approach to the inspection of hospitals is at a
more advanced stage than their proposals in primary care or adult
social care. Professor Field and Ms Sutcliffe both joined the
CQC in October 2013.
16. The Chief Inspectors are tasked with leading
specialist inspection teams and developing the revised model of
inspection which the CQC has launched. The Chief Inspectors of
Hospitals and General Practice will also be responsible for developing
the ratings system for these parts of the health system. Another
key function of the Chief Inspectors will be to:
use the expert findings, ratings and judgements
of their teams of inspectors, together with information and evidence
held by CQC and our partners in the system, to enable CQC to provide
a single, authoritative assessment of the quality and safety of
care of the services we regulate.[20]
17. The CQC's written evidence said that Chief Inspectors
will be responsible for ensuring that "appropriate action
is taken against providers where necessary, and will be working
with our partners in the regulatory and oversight system"[21].
In relation to Sir Mike Richards's role as Chief Inspector of
Hospitals, the CQC say that he will be "working with Monitor,
the NHS Trust Development Authority and NHS England to implement
the Single Failure Regime for NHS and Foundation Trusts."[22]
18. It has been proposed by the Department of Health
that the Chief Inspectors of Hospitals, General Practice and Adult
Social Care be established as permanent statutory positions rather
than simply appointments within the CQC. The Department of Health's
written evidence said:
The Department intends that Chief Inspector positions
will be enshrined in law, through the Care Bill currently in the
House of Lords. This will place the positions on a permanent footing
and ensure that individuals who are appointed to the roles are
able to speak up for patients and provide clear judgements about
quality of care. As a Unitary Board, the Chair and non-executive
directors will appoint executive members to the Board without
Secretary of State intervention. The requirement to appoint Chief
Inspectors to three of these executive member posts will not alter
the governance arrangements of CQC. The Chief Inspectors will
be accountable to the Chief Executive and the Board, will act
under the powers of CQC and will remain employees of the CQC.[23]
19. David Behan explained in more detail how he expects
the relationship to develop between the Chief Inspectors and the
Chief Executive, he said:
I see my job as to support the chief inspectors
to do their job. I am the accounting officer and the chief executive
of the organisation. That is how I see the difference. I do not
see myself making operational decisions, but, if an internal appeal
is required on a decision made by a chief inspector, it may well
be that I would consider an appeal, in the way that that operates
internally.[24]
He added that putting the Chief Inspectors on a statutory
footing "preserves their role in statute so that it cannot
be done away with, in a sense. It does not invest in them special
powers."[25]
20. David Behan provided greater clarity about the
organisational arrangements and the mechanisms for accountability
that will apply to the Chief Inspectors. The Committee will,
however, continue to follow the evolving relationship between
the Chief Inspectors and the Chief Executive of the CQC, who will
retain responsibility for strategic policy and operational decisions.
21. The Committee welcomes the fact that the Chief
Inspectors are accountable to the CQC Board. 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 in order to
maintain a consistent approach on these key issues across the
activities of the CQC.
Definition of Standards
22. The CQC has announced that it will now assess
the quality of hospitals against a range of standards which are
divided into three groups:
i. The Fundamentals of Care
ii. Expected Standards
iii. High-quality Care
23. The CQC launched a consultation on these standards
in July 2013 and the Department of Health plans to "consult
on the new regulations this Autumn setting out these standards,
reflecting the findings of the consultation [...] the new regulations
should come into force from April 2014."[26]
The Fundamentals of Care
24. The Department of Health is yet to consult and
the new standards have not been formally established, but it is
expected that the fundamentals of care will be based on the easily
identifiable basics of care which can be "understood by all".[27]
The CQC's strategy document announcing the reforms said that:
There will be immediate, serious consequences
for services where care falls below these levels, including possible
prosecution. Anyone should be able to recognise a breach of the
fundamentals of care, even in the absence of specific guidance.[28]
25. 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. Under
the existing regulations these steps are rarely taken, even in
cases of serious and blatant breaches, as warning notices must
be issued in the first instance. A consequent improvement in performance
achieved within the time stated in the warning notice means a
provider has returned to compliance and a prosecution is no longer
possible.[29]
26. The Committee notes the intention to revise
the CQC's powers to enhance its ability to quickly prosecute directors
and corporate bodies in the most serious cases. We believe, however,
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. The
Government and the CQC should keep these powers under review to
ensure the CQC enjoys a sufficient range of sanctions to levy
against failing providers.
Expected standards
27. The expected standards are to be directly linked
to five key questions which have been established by the CQC.
These standards will form the principal focus of the inspection
process and will be assessed by asking the following key questions
about providers and their services:
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?[30]
Shortfalls in meeting these standards will be reflected
in inspection reports, and ratings decisions, but will not necessarily
result in immediate action to suspend the operator's licence or
individual prosecution.
High-quality Care
28. The definitions which will be applied to high-quality
care have yet to be established but the CQC has said that they
are likely to be related and of a similar style to NICE quality
standards.[31] The CQC
said:
Our inspectors will use good practice guidance
developed by these other organisations to identify and describe
whether a service is providing high-quality care. We will also
look for where providers are using new ways of providing good,
innovative care.[32]
Application of Standards
29. In evidence to the Committee the English Community
Care Association questioned whether differentiated standard levels
were practical:
We question the need for "fundamentals of
care" to be detached from "expected standards"
in the manner proposed. We are not confident that members of the
public will be able to understand the qualitative difference that
is intended to separate fundamentals from expected standards.[33]
30. David Behan said in oral evidence that the CQC
is still working on developing the fundamental standards and added
that they will eventually be set out in regulations.[34]
Mr Behan added that the CQC will:
inspect all services against the five key questions
that will drive a rating on that four point scale of outstanding,
good, requires improvement or inadequate. The fundamental standards
will be set in law so that they are enforceable.[35]
31. In their written evidence the Royal College of
Nursing say that the CQC will have to develop "tangible,
transparent standards that can be inspected against".[36]
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.
32. In our last report the Committee found that:
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'.[37]
The committee believes that the CQC's broad approach
of linking five key questions to the inspection of expected standards
and linking immediate regulatory action to breaches of fundamental
standards has the potential to simplify the regulatory process.
Provided the CQC focuses on evidence of outcomes achieved, there
is now an opportunity to move away from a system that focused
on inputs and failed to illustrate a realistic picture of the
standards of care offered by providers.
33. The ultimate test of the new standards will
be whether they are meaningful in relation to the everyday experiences
of patients, care home residents and the public. The committee
welcomes the commitment on the part of CQC to take immediate action
against providers who fail to meet fundamental standards and therefore
breach their registration requirements. If applied firmly, we
believe this measure has the potential to considerably enhance
the credibility of the new system.
Implementation of reform
34. The evidence provided to the committee shows
that the CQC has an ambitious timetable for reform of registration
and inspection. In October 2013 the CQC launched its new risk-based
system of inspection. The new model is being rolled out through
2013-14 and the CQC has said that the risk-based regulation of
all sectors is expected to be "fully operational in 2014-15".[38]
The CQC proposes to have undertaken their first wave of inspections
and published ratings across the majority services by July 2015[39],
but the Foundation Trust Network (FTN) has warned that this process
could be "disruptive to providers".[40]
35. The FTN's evidence to the Committee sounded a
note of caution about the emphasis placed on the sectors covered
by the three Chief Inspectors and their respective teams. In the
past FTN members have criticised the CQC for "being too acute
or social care focused, causing particular problems for community,
ambulance and mental health services"[41]
and the FTN argued that:
The CQC is in danger of falling into the same
trap with the appointment of Chief Inspectors of Hospitals, Social
Care and Primary Care, and delaying the development of the new
regulatory approaches for community, ambulance and mental health
services until much later.[...]
There is a danger of over-focusing on the regulation
of hospital-based care, which ignores the trends to provide more
care in community-based settings and for trusts providing a mix
of types of services or care that is more integrated. Many acute
trusts now also provide community services, while some mental
health providers provide more community health services than mental
health services. Members from integrated and specialist trusts
participating in recent FTN/ CQC engagement events highlighted
how many aspects of the new regulatory and surveillance model
did not apply to them.[42]
36. It should be noted that the details of standards,
inspection methodology and ratings have not yet been confirmed
by the CQC. The system in social care in particular is still under
consultation and David Behan conceded that: "To be brutally
honest, we need to do more work on developing that methodology
and model."[43]
37. In response to the suggestion from the FTN that
the CQC's strategy may be too focussed on three core areas David
Behan said "If everything is a priority, nothing is."[44]
The initial focus has been "to sort out what we are doing
around acute hospitals".[45]
Mr Behan explained that once the hospital programme is in place
the CQC "will begin to tackle what we are doing around independent
healthcare, mental health, community trusts, and ambulance services."[46]
38. It was also clear from the evidence presented
that the CQC does not yet have a firm plan for the surveillance
and inspection of home care services which, by their nature, are
more difficult to observe. David Behan told the Committee that:
A lot of our methodologies are built on being
able to observe care [...] but of course a lot of care is not
delivered in an observable set of circumstances and situations.
Personal care takes place in somebody's own home, and how we assess
the quality of that is something that we need to work through.
Remember, there are 8,000 domiciliary care agencies delivering
care to individuals in their own homes. By definition, it is not
in an organisation like a hospital, a care home or a school, so
it requires different approaches. [47]
39. The FTN said that some of their members "have
expressed disappointment at the language of 'hospitals' in recent
CQC documentation"[48]
which underlines David Behan's statement that hospital regulation
has been prioritised. If the CQC seeks to prioritise everything
then they will prioritise nothing, but they must now begin to
provide detailed information to the full breadth of health and
social care providers to build support for reform across the system.
At our next accountability hearing we expect the CQC to present
clear details of how the effective registration, surveillance
and inspection procedures will be extended beyond hospitals to
cover adult social care and general practice. In particular the
CQC should by then have developed clear and creative proposals
for scrutinising the quality of care delivered by providers in
a person's own home.
20 CQC, A New Start, June 2013, p 20 Back
21
CQC (ACQ 02), para 28 Back
22
Ibid. Back
23
CQC (ACQ 01), para 11 Back
24
Q15 Back
25
Q16 Back
26
CQC (ACQ 01), para 15 Back
27
CQC, A New Start, June 2013, p 13 Back
28
Ibid. Back
29
Department of Health, Strengthening corporate accountability in health and social care,
July 2013, p 12 Back
30
CQC, A New Start, June 2013, p 2 Back
31
Ibid, p 16 Back
32
Ibid Back
33
CQC (ACQ 04), para 2.3 Back
34
Q38, Q41 Back
35
Q38 Back
36
CQC (ACQ 07), para 3.5 Back
37
HC 592, para 29 Back
38
Care Quality Commission, Business Plan 2013-14, p 20 Back
39
CQC (ACQ 020), Annexe 1 Back
40
CQC (ACQ 09), para 3.2 Back
41
CQC (ACQ 09), para 9.1 Back
42
Ibid, para 9.2 Back
43
Q11 Back
44
Q29 Back
45
Q29 Back
46
Q29 Back
47
Q107 Back
48
CQC (ACQ 09), para 6.7 Back
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