Conclusions and recommendations
Purpose of the CQC
1. 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. (Paragraph 11)
Chief Inspectors
2. 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. (Paragraph 21)
Definition of Standards
3. 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. (Paragraph 26)
Expected standards
4. 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.
(Paragraph 32)
5. 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.
(Paragraph 33)
Implementation of reform
6. 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. (Paragraph 39)
Surveillance
7. 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. If the CQC's surveillance model cannot pre-empt
high profile failings it will be viewed as purely reactive and
will not be regarded as a credible basis for regulatory activity.
(Paragraph 43)
8. The Committee welcomes
the importance attached to staffing levels by the CQC. We believe
that analysis of staffing figures should not only be part of inspection
but should also form a fundamental part of the surveillance model.
Staffing data should extend beyond the ratio of registered nurses
to patients working on a hospital ward and should examine other
measures, such as consultant coverage in emergency departments,
which is a crucial factor in improving patient outcomes. Information
gathered from surveillance which suggests that staffing levels
are inadequate should be a trigger for inspection as "the
quality of care that people receive is related to the number of
staff on duty." (Paragraph 46)
9. The Committee welcomes
the commitment made by the CQC that the fundamental standards
by which providers are registered will incorporate appropriate
staffing levels. It is essential that those providers that fail
to achieve adequate staffing levels are aware that they are in
breach of fundamental standards and therefore liable not only
to inspection but also to regulatory action including prosecution.
The regulations have yet to be published and it is vital that
the public have the opportunity to scrutinise how they define
an 'appropriate staffing level'. (Paragraph 48)
10. 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.
The Committee believes that would allow more information to be
quickly factored into the CQC's surveillance model which already
includes 'never events' in its first tier of indicators. (Paragraph
51)
Financial monitoring of social care
11. Undertaking the
financial monitoring of adult social care is a significant challenge
for the CQC and it is essential that they procure the right skills
to fulfil this role. David Behan noted in his evidence that there
was a close correlation between poor quality and poor financial
performance, saying that "[m]aking a distinction between
finance and quality is a false distinction." We do not dispute
this point, but the Committee believes that, ultimately, it is
easier to identify and address poor quality at an early opportunity
than it is to demonstrate that a provider is financially distressed.
(Paragraph 56)
12. We recommend that
the Government should reconsider its decision to allocate this
responsibility to CQC and that it should ask Monitor to undertake
this role. Although this development would divide oversight of
adult social care between Monitor and the CQC, it 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. (Paragraph 57)
13. The Committee
welcomes the introduction of the fit and proper person test for
senior governance positions, but does not understand why it is
proposed to exclude Chairs of NHS Trusts and NHS Foundation Trusts
from the scope of this test. It does not believe that this exclusion
will be understood or accepted by public or patients. (Paragraph
63)
Inspections
14. The CQC has an
important role in providing quality assurance for a vital public
service, but it cannot guarantee care quality. Primary responsibility
for the quality of care delivered to patients rests unambiguously
on the staff and management of care providers. (Paragraph 68)
15. The Committee
believes that generic inspection was a failure and the new model
is a necessary step towards making the CQC an effective regulator.
The proposed system represents a comprehensive improvement but
the CQC must ensure that inspection is accurately targeted at
risk. Surveillance will not always identify specific risks in
outstanding hospitals and some high risk services will require
frequent inspection even if they are regularly classified as 'outstanding'.
(Paragraph 69)
16. The Committee
welcomes the CQC adopting our recommendation to assess the culture
of providers as a core part of the inspection process. This assessment
must 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 frontline staff. (Paragraph
73)
17. In the report
on the Committee's 2012 accountability hearing with the CQC we
concluded that:
A key element of this assessment [of culture]
should be a judgement about the ability of professional staff
within the organisation to raise concerns about patient care and
safety issues without concern about the personal implications
for the staff member concerned.
The Committee believes that the CQC should undertake
an assessment of both the number of concerns raised by staff members
and the way in which those concerns have been addressed. This
would serves as a useful proxy by which the CQC can begin to measure
the culture of an organisation. (Paragraph 74)
Staffing and workforce planning
18. 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 provides
regular reports to Parliament on progress towards delivery of
this objective. (Paragraph 80)
19. Substantial additional
resource is being directed towards the CQC; the Committee recommends
that the CQC Board reach early decisions about the allocation
of this additional resource and that it make its decision public.
(Paragraph 83)
Ratings
20. The Committee
welcomes the decision to publish ratings for all health and care
providers. It is essential that the CQC act quickly to establish
public understanding of, and confidence in, the ratings system.
(Paragraph 86)
21. David Prior informed
the committee that the CQC was "going to consider writing
to residents of a care home, for example, telling them in words
of plain English, 'This is what we have found'." 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. (Paragraph 88)
Internal culture
22. The Committee
welcomes the CQC management's commitment to this process of culture
change within the organisation and, in particular, their commitment
to monitor progress in delivering this objective. (Paragraph
92)
23. Creating a mechanism
for staff to report bullying and harassment to a director at a
very senior level will help the executive team and the Board maintain
a realistic understanding of the experiences of the CQC's frontline
workforce. Whilst this is an important step that delivers necessary
senior oversight, this system, in itself, is not enough to eliminate
the culture that has produced bullying and harassment.
(Paragraph 93)
24. 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 and that inspectors are be able to complete
their work thoroughly (including weekend and out-of-hours inspections)
without being required to manage unreasonable workloads. (Paragraph
94)
Funding
25. 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. (Paragraph 100)
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