Care Quality Commission Board meetings, 31 Jul 2013

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From YouTube: Care Quality Commission Board Meeting 31 July 2013

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Agenda for the meeting of the Care Quality Commission on 31 July 2013:
1. Apologies and declarations of interest 00:00:01
2. Minutes of the meeting held on 16 June 2013 00:00:18
3. Matters arising and action log 00:00:36
4. Morecambe Bay Review - Grant Thornton 00:00:42
5. Update on Mid Staffordshire Inquiry recommendations 00:29:00
6. Chief Executive's report 01:42:13
7. Acute hospital inspection 01:51:31
8. Surveillance model update -to discuss priorities for the next phase 02:25:28
9. Update on Winterbourne View 02:28:58
10. Corporate performance report, including finance (Q1) KPIs and
performance measures 02:57:39
11. Update on thematic activity programme 03:24:08
12. Strategic partnership plan -to Board for review and approval 03:35:18
13. Audit of document retention -terms of reference 03:43:28
14. CRM hosting and application support contract award 03:44:53
15. Healthwatch England 03:51:28
16. ARAC -report back from 16 July meeting 04:07:40
17. Board forward plan 04:07:51
18. Any other business 04:07:55

Read more about CQC's Board Meetings at http://www.cqc.org.uk/public/about-us/our-people/board-members/board-meetings

A

≫≫≫ Robert Francis is not here yet,. He was due here at 9, but he's on his way,.

A

So he won't be long and the same with Camilla.

A

We've got apologies from Lewis Appleby who's, away.

A

Is everyone happy with the minutes?

A

I mean they are far too long,. I've already told Claire that, we're going to cut them.

A

Down by at least half for the next meeting,, but we thought they should be.

A

Full,, given the content of the last meeting,, but is everyone who was at.

A

That meeting happy with them? Thank you.

A

I think all the matters arising are covered by the agenda,. If they're not I'll,.

A

Pick anything up at the end. Now, we were going to start with the update on the Mid Staffs inquiry with.

A

Robert Francis,, as he's not here we're going to skip over that one and come.

A

Back to it, and ask David to start on the Morecambe Bay review, please.

B

≫≫≫ Okay. Thank you David, good morning, everybody.

B

So, the Grant Thornton report contained a number of comments, observations.

B

And recommendations in relation to CQC's practices and procedures,.

B

And what this report is, an attempt to do is set out a response to those.

B

As, you know we published this report on the 19th of June, David and myself.

B

Appeared before the Health Select Committee hearing on the 3rd of July.

B

Where the focus really was on the history of the decision-making around.

B

The publication of the report and the issues contained therein.

B

We also had contact with both Cumbria and the Metropolitan police, and there's.

B

Also, the intention from the Department of Health to have a further independent.

B

Inquiry into Morecambe Bay,, so what this report is doing is attempting to.

B

Summarise where we're up to against all of those objectives.

B

So, if I go through briefly David,, without presenting each item.

B

Section 3 of the report is really responding to the comments contained.

B

In the Grant Thornton report about the policies, procedures and practices within.

B

Cqc and how we take those forward.

B

So we cover, initially, the approach to inspection, the majority of the issues.

B

Raised are picked up through the strategy and there's a further report.

B

From Mike later on in the agenda,, which sets out in more detail, how we intend to.

B

Move forward inspecting hospitals,, so I'll not cover that in any detail and leave that to Mike.

B

We further cover the approach to risk assessments in the way that we make.

B

Our judgments about services and again the strategy, picks up the importance of.

B

Surveillance and indeed the 18 hospitals that Mike will inspect through the latter.

B

Part of this year have all been selected using that surveillance, methodology,.

B

So it's now beginning to be applied and is a more transparent approach to risk. Assessment.

B

The duty of candor is currently being discussed with the Department of.

B

Health, in terms of the regulatory changes,, but the issue from Grant.

B

Thornton was really about the Fielding report and whether CQC knew about.

B

That report, and at what stage it knew about it.

B

CQC, does now oblige providers to disclose critical information following.

B

Registration and that's one of the changes and we'll make further changes. There.

B

The Care bill currently before Parliament, just gone through the.

B

Committee stages does introduce a failure regime,, which will have a clearer.

B

Road map for how failing organisations need to be dealt with, and also Grant.

B

Thornton repeats many of the recommendations that the Deloitte.

B

Report made about how we can improve the way that we carry out investigations.

B

Recommendations about corporate governance and the first meeting of the.

B

Independent governance committee met yesterday and recommendations about.

B

Operational governance, which again will be picked up later in the year, and we do.

B

Intend to publish the full list of Trusts in September of this year.

B

We'll pick up the recommendations about training and guidance and an.

B

Important piece of work moving forward is the development of the academy,.

B

Which is to support the developments of our staff and their training, and I think.

B

That's picked up later in the seminar this afternoon for board members.

B

I've covered the changes to registration,, we'll set performance targets, much.

B

More clearly to reflect our changed activity and that work is going on.

B

And again, one of the critical issues in Grant Thornton was how we worked.

B

With other organisations, other regulators, parliamentary and Health.

B

Service, ombudsman and a lot of work is being taken forward in that respect.

B

So, that's the work, we're picking up through Grant Thornton.

B

There is an annex which goes in more detail to the specific paragraphs in the.

B

Grant Thornton report that I hope reads back to the paragraphs in the covering.

B

Report and demonstrates the connection between our current work programmes.

B

And the Grant Thornton recommendations.

B

Additionally,, we gave commitments to the select committee and, as is usual in.

B

These cases, we followed that up in writing to the select committee and that.

B

Letter is attached as an appendix to this report.

B

We also gave commitments to follow up against current and former members of.

B

Staff, to consider whether there were any employment issues that need to be.

B

Pursued, we've retained Hempsons to advise us on this and that work is.

B

Current in terms of current members of staff,, literally that work is going on in realtime,, now.

B

In terms of referrals to the police,, there are two dimensions to this.

B

The first was the dimension of any criminal investigations that Cumbria.

B

Constabulary were undertaking and a copy of the Grant Thornton report was.

B

Forwarded to Cumbria Constabulary following the last meeting, where that.

B

Report was considered. They've written back saying they don't think, there's any grounds for any further.

B

Consideration of that report in that respect.

B

There was a second issue, which followed an MP, making a referral to the.

B

Metropolitan police about misfeasance in public office.

B

Now we learned yesterday that the Metropolitan police have now referred.

B

That to Cumbria, Constabulary and they'll have to consider that in their own time.

B

And then, the final matter, well penultimate matter covered in the report.

B

Is the announcement by the Department of Health that there will be a further.

B

Inquiry into Morecambe, Bay and Dr Bill Kirkup has been retained by the.

B

Department of Health to lead that inquiry,. My understanding is that.

B

Dr Kirkup has been meeting with the families at Morecambe, Bay and.

B

Following that meeting, he'll finalise his Terms of Reference for how that should move forward.

B

And then, the last issue I draw attention to is the fact that James Titcombe,.

B

Who was one of the complainants in the, covered in the Grant Thornton report?.

B

Continues to voice his concerns as to whether the conclusion of the Grant.

B

Thornton report meets his original concerns.

B

Subsequent to James raising those concerns he's received a letter from the.

B

Chair of the Health Select Committee,, Stephen, Dorrell, and I understand that.

B

James is accepting of the explanation that Stephen Dorrell has offered him in.

B

Relation to the relationship between the work that we did and the commitments.

B

That we gave to the parliamentary ombudsman and the appropriateness of that, effectively repeating what we said at the select committee,, namely that we.

B

Should make independent decisions and they should be not contingent on what.

B

Any other organisation or individual determines.

B

We considered this at the governance committee yesterday and I've been.

B

Asked to write directly to James Titcombe, setting out the importance of.

B

Our independent decision-making and that not being contingent on any other.

B

Organisation, so I'll do that in the next 24 hours.

B

So I think what I'm asking chair, is for the board to note and comment on the.

B

Activities that we've set out. I hope that's a full,, well not explanation, but it contains an explanation of a full.

B

Set of actions which are being taken forward to respond to the changes, thanks, chair.

A

≫≫≫ Thanks, Robert. Do you mind if we just finish off this item and come back to you in a minute? We won't be long. I, think., Kay?,.

C

≫≫≫ Thank you for the report, there's two things.

C

One is whether,, I think it would be quite helpful if the Davids could report back.

C

On the meeting that you had with the families at Morecambe Bay, just to.

C

Report to the board and the public on how that went and what you got from it,.

C

I've had some positive feedback about it from the families, but I think it.

C

Would be quite helpful for the rest of us to hear how it went.

C

The other issue is,, it's actually not a central issue in the Grant Thornton.

C

Report, but I think it is a central issue in relation to the, what happened at.

C

Morecambe, Bay and elsewhere, and that's this issue around investigations.

C

Because, what I hear at Morecambe, Bay and from other family members, and this.

C

Was yesterday hearing another two, is that there is really not clarity about what.

C

Happens when things go very badly wrong, you know,, when someone,.

C

This is in health care,, where there is an unexpected death or a serious untoward. Incident.

C

And we've got the ombudsman,, we've got our investigation. Powers, we've got.

C

The coroner, I'm just thinking of Morecambe Bay, with James Titcombe,.

C

Initially, the coroner was not going to look at that and he pushed and it ended up.

C

With a rule, 43 letter.

C

So, it's very hit and miss, I, don't know exactly what the answer is,, but we've got.

C

Our investigation, powers, there was a lot of criticism about disbanding the central.

C

Investigation team, and we might want to,, not necessarily think, oh well. We.

C

Recreate that, but to actually think a bit more about,, because we have the.

C

Deloitte review,, which essentially said how we'd been doing investigations.

C

Wasn't really helpful, shall we say, but I'm, not sure how that's going to,, how our.

C

Investigation function is going to pan out as we go along, and whether that --.

C

There is going to be a central type investigation or whether it is going to be.

C

Absorbed locally and if it is absorbed locally, then we need to make sure we've.

C

Got the skills there. But, there's also this wider issue about investigating in general,, because there.

C

Doesn't seem to be guidance or standards as to what should happen and.

C

Families are left,, sometimes not able to bury their family members. To be honest,.

C

And they don't think lessons are learned,. They feel that Trusts cover up,.

C

And it's all a bit vague.

C

I just wondered if, as well as considering our investigation role,, whether it was.

C

Worth taking a lead in trying to sort of thrash that out more generally?.

C

Because, it isn't just about us.

A

≫≫≫ Thanks very much Kay,, maybe on the second part we might come back to.

A

You Mike on that to think about what might trigger an investigation from our point of view.

A

But on the meeting with the family,, do you want to just do that? David?.

B

≫≫≫ Okay, so following one of our conversations with James Titcombe.

B

David gave an undertaking to go up and meet the group of families that are being.

B

Convened by James and other colleagues, other families in Morecambe.

B

Bay,, who all have an experience of maternity services in Morecambe, Bay.

B

Which has left them with complaints to make, grievances to air and a.

B

Dissatisfaction generally.

B

So we went up last Thursday to meet five families who had all in common,.

B

Had lost their children at Morecambe, Bay.

B

And over about two and a half hours, they told us their stories of their.

B

Experiences, and each one told their own story.

B

It was powerful and humbling, because these were,, if I use this, I, don't mean.

B

This in a dismissive way,, but ordinary people,, they were not part of any.

B

Organised groups or anything else, who just told their stories in their own language.

B

The common issues, which came out, I'm sure Robert, will echo this when he.

B

Speaks,, were they didn't feel, listened to,? They didn't feel believed,. They felt fobbed.

B

Off, they said they were dealt with by people who felt they had got an aura of.

B

Invincibility, was one of the quotes that they used.

B

They felt they had been spoken to dismissively and without compassion.

B

As, they all told their stories,. What emerged was what they had got in.

B

Common, they had all been in hospital on a Saturday,. There were complications.

B

With the birth that they were all asking for Caesarian sections because of the.

B

Complications with the birth and they felt they weren't being listened to in that.

B

Request and their requests were being dismissed.

B

Following the deaths of their children, they felt it was difficult to be listened to. Again.

B

A number of the people where liability had been admitted felt that they had not.

B

Had an apology for what happened.

B

And felt that that they had not been listened to or treated in an appropriate.

B

Way,, in fact, they had come together as a group, largely by understanding each.

B

Other's stories through local media publishing their stories, so in a sense.

B

The press acted as the means of sharing stories and them gathering together.

B

Which has resulted in this action group being taken.

B

We understand there's about 50 families that are in this position, all are.

B

Consulting legal advisers in relation to this, two different firms, one has about.

B

30 and one has been 20,, so a small proportion of the total families,, but the.

B

Stories were so powerful and humbling and I think we both came away struck.

B

By the power of those stories,, but also the importance for us of actually.

B

Understanding the voice of people who have a complaint to make, how we pick.

B

That up in our inspections, moving forward, how we assemble some of the.

B

Data that we need to explore just how people's experiences of services.

B

Are captured at a local level and how improvements take place.

B

It flagged up issues around engagement with people,. It flagged up the issues.

B

Around governance and some of the challenges that exist for liability and.

B

Apologies to be issued.

B

About, how open organisations can be if they know that they've actually not got.

B

Something as right as they need it to be, or where they've just got it plain wrong. Quite frankly.

B

I think, speaking to your second point: Kay, I'll, let Mike come in on it, but I think.

B

It also speaks to. When do you detect a pattern from individual complaint?.

B

When does one story become a trend and how do we assemble that?.

B

And one was struck with some of these deaths began to occur in 2006/7 if I've.

B

Got the chronology, and went on over a period of time,, so each was an individual.

B

Story powerful in its own right,, together, the five stories made quite an impact,.

B

Even more than five stories would make a bigger impact,. So how do you get at those stories?.

B

Is high Caesarian sections, a good sign or a bad sign in a hospital?.

B

So there's some judgments to be made about how we assemble those stories.

B

But nonetheless, powerful, powerful and humbling stories.

B

I, don't know whether you want to add anything.

D

≫≫≫ I'll add one thing, one of the women there called Margaret lost her baby on.

A

Christmas Day 2010 and we had given,. We had inspected that maternity unit in June 2010.

A

If we had found something then that baby might have lived,, so it brought it.

A

Home to me just how important it is, our inspections.

A

That was pretty grim actually,, but Kay?.

C

≫≫≫ Just on the point of the wider inspection thing: do you think there is a possibility of us taking some kind of leadership, role or trying,, because there.

C

Is our inspection role, but there's also the wider, it takes in the coroner's office and.

C

The ombudsman,, it's all very vague and hit or miss,. It doesn't seem right that in.

C

An unexpected death or serious untoward incident, it is not,. There are not.

C

Standards for investigating that.

E

≫≫≫ I don't have an immediate answer for you Kay,, except to say that with our.

E

New hospital inspection programme there will be three triggers that we'll be.

E

Doing our comprehensive inspections, we'll be doing follow-ups from those.

E

Comprehensive inspections, but we'll still continue to do responsive inspections.

E

And, what I think we need to do some work on is: what will the triggers be for a.

E

Responsive inspection?

E

How many, never events,. Is it a single, never event, for example, or is it more than that?.

E

What are the clusters of things going on?.

E

And one piece of work that we set in train just yesterday was looking at what.

E

Had triggered an investigation in one region over the last few months,.

E

Because I need to get an impression of that to see if we can come up with some.

E

General principles from that about what should be done., So I, think that's something that definitely is in our sights but haven't yet got an answer.

F

≫≫≫ More just of a very basic question: about, there's something here about in.

F

The grid about board agendas and minutes, failure to discuss UHMB in the.

F

Past,, it's a more general question about the worry list, and not just when.

F

Something is spotted,, but the follow-up to worry,. To what extent is that featuring.

F

In the -- we're new board members,, but is there something we can do more.

F

Robustly to bring that stuff surfacing at every meeting or at an appropriate frequency?.

F

Special investigations may be a way of getting it on to the agenda, as a.

F

Constant agenda item,: it's not just the Morecambe Bays,, it's actually. The worry.

F

List where there's some lower level follow-up that actually should escalate.

F

And the extent to which the board should be cited on that.

B

≫≫≫ I think that's an important point. Jennifer, I do an e-mail out to board.

B

Members, every Friday, where I try and get in the topical issues that are coming.

B

Through, so there's a -- boards. Members are advised in realtime.

B

We've said that we'll publish the list of inspections based on our surveillance.

B

Methodology in September of this year, and I think one of the references in the.

B

Report about governance and the need to get that operational governance stronger.

B

Is to ensure that there is that line of sight between the board and those.

B

Issues that we are concerned, about.

B

I, think on investigations, just to connect the investigations,. The Deloitte report.

B

Said this is a strategic tool which is not being used, strategically,, it's being used.

B

As part of a tariff. So, when all else fails, investigate.

B

And, the recommendation from Deloittes, which we have accepted, is that we'll use.

B

These strategically and not part of a tariff,, so Mike's point about responsive.

B

Inspections is really the tool that we've got where we continue to have concerns.

B

About SUIs,, never events or where we think there is an emerging pattern and.

B

It's a surveillance approach that will give us the intelligence whether there is a.

B

Pattern which will then trigger whether there needs to be a responsive, inspection.

B

And, our commitment is that we'll, in a sense, have monthly meetings on the.

B

Surveillance to see what changes are taking place within a month about.

B

Whether any immediate action needs to take place.

B

So our month end account will not be a financial account, but what does the.

B

Surveillance information tell us about whether there are any triggers in that.

B

Intelligence,, whether we need to take further activity.

F

≫≫≫ That would come to the board and there would be named sites that would.

F

Be -- yeah, thank you.

A

≫≫≫ Just elaborate on that slightly please.

G

≫≫≫ So, we have a paper later that looks a bit about how surveillance will roll out.

G

Across the different sectors- because this is true for mental health and.

G

Learning. Disabilities, as it is for acute health for example.

G

We'll expose on a monthly basis what our statement is telling us.

G

I think the piece we need to get right is not to just be saying, and it's the same.

G

Ten hospitals on average we're most worried about,, but also to flag up where.

G

Something has substantially changed, whether that's a mortality alert and we.

G

Have,, that's part: that's most developed, so far.

G

But I think we need to be clear both operationally and to the board, where.

G

Something substantial has changed. That would therefore trigger something.

G

Different to what you might have otherwise expected.

A

≫≫≫ Anna?.

H

≫≫≫ Sorry: this is a really geeky point,, but I'm really conscious that in relation.

H

To what Jennifer was saying,, we've had lots of conversations in the board before.

H

Current members arrived- and it's really important- that we have this conversation now.

H

But we have the audit and risk committee, which plays a role in looking.

H

At risk, we've, the new governance committee, which plays a role in relation.

H

To at least whistle blowing and possibly some other elements,, we've got the.

H

Weekly reports that David, does, and I just think there's a little bit of narrative.

H

We need to have around that, about how things go from A to B and how they then.

H

Surface as a collective set at the board at appropriate intervals.

A

≫≫≫ Absolutely.

A

I was asking Michael on your right, Michael Mire, that is to sort of think.

A

Through this whole governance, structure, relationship between the audit and risk committee,, new governance committee and the board, so we're absolutely clear where responsibility lies and I think we'll try to bring a paperback.

A

At the end, in the September meeting, okay?.

I

Steve? >>> It would certainly help me if we could have something come to the board.

I

That puts the investigations into context of the new inspection regime.

I

We saw the Deloitte report and David said we accepted all the recommendations, but I'm, not quite sure where,. This is under the Section 48.

I

Powers, I understand?, The, investigations. Where, we're now placing that, in the context of the whole new range of.

I

Inspections,- and it would certainly help me if we could have that discussion,.

I

Because it is a very different power and I think we held it in reserve rather than.

I

Used it since the Deloitte, report, and I think the Deloitte report criticised us for.

I

Making it just another type of inspection,, it wasn't much more than that.

I

And I think we need,. It would help me to have that discussion here about how.

I

That fits into the spectrum of the powers that we exercise.

A

≫≫≫ Maybe Mike in September. We can address that issue, okay?.

A

Thank you. Paul?.

J

≫≫≫ Two linked things.

J

It seems to me that the NHS for some time has been trying to have an agreed.

J

Definition of what a severe untoward incident is.

J

And back to your point,, the public, and we need that to be settled and at the.

J

Moment it's very different in different Trusts, and I think it would be, wouldn't.

J

Be beyond Monitor and the TDA and ourselves to say this is an SUI and.

J

Therefore, we know how many SUIs are in different places,, because it really --.

J

Within a Trust, it can vary as they change the definition. Quite a lot,.

J

So I think we need that basic information.

J

And I think the second thing that links to that, that Kay, raised and I think this.

J

Might be something for Healthwatch to pick up, is after Ann Clwyd reports on.

J

Complaints,, there's going to be quite a range of different things that the public.

J

Can do, that involves coroners, does occasionally involve the police,.

J

Does involve a complaints, procedure, might involve, us, might involve the.

J

Ombudsman and there needs to be some sort of route map to get through this.

J

What, do you do,? When do you do it?.

J

Because, it is just,, as you were listening to those stories,. You could pick an.

J

Accountability out of the air and try and get some and then there's CCGs and.

J

Trust,, so all of that needs to be --. I think it probably would be quite useful for.

J

Healthwatch to say, we'll explain this to the public.

J

And to the NHS, and to us.

A

≫≫≫ Anna: do you want to...

H

≫≫≫ Just to say that we've started.

H

I think it's a good suggestion that we should finish. So we've put a schematic on the website which local Healthwatch are adjusting.

H

And developing for their local environment with names and contact details and the schematic at the moment is about how to complain. In the first.

H

Instance,, which is frankly complicated enough as it is and needs considerable.

H

Change in order to make it accessible, but this is an attempt, at least to explain.

H

To people where they need to go for which bit, so we're rolling that out.

H

With local Healthwatch to try to ensure if people can't find their way through the.

H

System that they are helped., And I think this is --. This notion of how do I get something then further.

H

Investigated beyond complaints is an interesting addition, so I'll certainly take that away. Paul.

A

≫≫≫ I was very struck by Lisa, one of the ladies at Morecambe Bay, saying she.

A

Was confronted by this aura of invincibility,, which I can totally.

A

Understand,, how do you start to take on the NHS?.

A

≫≫≫ Can I just say in respect of that,. One of the things certainly emerging.

H

From our complaints, work, very, very strongly is the sense that two things,.

H

One is the need for enhanced and more accessible advocacy on behalf of.

H

Consumers and users of service in a situation where they have complaints or.

H

Concerns and feedback that they want to pursue,, precisely because they feel.

H

Vulnerable, very often in those situations, and because the system is really rather complex.,.

H

And what you see in, for instance, some of the things that Kay is saying is.

H

Someone taking on that role in a way which is accessible to some, but for.

H

Which many thanks, but not accessible to everyone.

H

So, the notion of advocates out in the system is really important and I think the.

H

Second element of that, then, if you're going to have a system which is more accessible in terms of help and support in that respect, is actually having a brand.

H

Around it, so people know that's where they can go for help., So. I think this is all part of making complaints and concerns actually work rather better.

A

≫≫≫ Thanks Anna. I think unless anyone wants to chip in again, I think that leads us on probably to.

A

Robert's reflections on your report in Mid Staffs, because there are some.

A

Common themes coming out on this discussion as well, so Robert can I hand it over to you?.

K

≫≫≫ Well. Thank you very much, David and I'm. Sorry that the transport didn't get me here on time!.

K

Well, thank you very much for inviting me to come and talk to you.

K

I'm sure we all now share a common experience and it's that, listening to.

K

David and David, it's clear to me: that's so,, of the impact that listening to.

K

Patients and their families in relation to their individual cases, had, has.

K

And, certainly the impact it had on me to spend in my first inquiry. Three.

K

Continuous weeks listening to and talking to families at the rate of about.

K

Three, a day, about their appalling experiences at Stafford, hospital,, all of.

K

Which is summarised along with many hundreds of other cases in the report.

K

Had a very profound impact on me. And. It taught me this, that it is, the reason we're all here and the reason.

K

Everyone is working in the Health. Service is actually to serve patients and.

K

To help them with their health, needs, and somehow or another, the system,.

K

Vast as it is, complex as it is, necessarily so,, has a tendency to forget that,.

K

Which is an extraordinary fact,, but it is true.

K

And so I firmly believe that the principle lesson to come out of the stories that I.

K

Heard and the account I was able to give about the system as a whole,.

K

Is that whatever else the system does and everyone in it,, we have to stop and.

K

Remember why the system is there, and we have to stop and listen to patients.

K

And their family, and allied to that is something,, an echo of which I've heard.

K

Here, just now, is that information coming from patients and their families.

K

Should not be rejected as being irrelevant or not very helpful, just.

K

Because it's an individual case.

K

I, as a result of what I have done, receive post as I'm sure everyone else.

K

Here, does, from individuals who have had usually rather bad experiences.,.

K

And, a fairly common theme,, not universal, but a common theme, is that.

K

The reason they've written to me and no doubt lots of other people is no one- has.

K

Actually responded to their case.

K

And, without that the harm that was originally done,, whether usually.

K

Unintentionally of course, sometimes carelessly, but always unintentionally,,.

K

At whatever hospital it, was, is actually aggravated,, and not only has someone.

K

Been injured and maybe in some cases has a patient died,, but their family are.

K

Then injured further by being ignored, or that's the way they feel.

K

So, the first lesson I think is: we really do have to listen to people and then.

K

Respond to them and interact with them and use the value that they bring to the.

K

System, because that's what they want,, they want things to change.

K

The second point is in relation to what we do know and what we are told about.

K

Various institutions, is that we all the time I, think need to assess what the.

K

Safety implications of that information, are.

K

We should not, in my view, wait for a perceived risk to become a reality,.

K

Represented by injured patients, people who are not treated, or worse.,.

K

And, we shouldn't be satisfied with theoretical action plans,, but where there.

K

Is a risk? We should act before that risk becomes reality, and we should also.

K

Look at information from the point of view of what it tells us about the current risk.

K

And I think perhaps too often in the past, risk is to patients, is treated as a.

K

Commodity in itself,, which either gets bigger or gets smaller.

K

But, no one is giving sufficient thought to the patients who are actually walking.

K

Through the door of the relevant place, then and there, who, by and large, will be.

K

Blissfully ignorant of the information that an organisation like this, for instance,.

K

Might have about what is going on in that institution.

K

So I think we need to, and I know that this work is going on. Here, develop an.

K

Appreciation of warning signs, not just evidence that something bad has.

K

Already happened,, but actually what are the signs that tell us that something is.

K

Going wrong and therefore something ought to be done now to prevent the.

K

Damage that might occur if nothing is done.

K

Now in relation to regulation,, as you know, I had to examine the lengthy.

K

Period of regulation,, different organisations, being reorganized,.

K

Thrown up in the air, different systems of actually working out where there was.

K

Cause for concern. And, while there are many ways of monitoring what is going, on, really I.

K

Came to the conclusion that, certainly for the moment, the only regulatory game in.

K

Town that actually really exposes what's going on is expert and rigorous inspection.

K

And generic inspection,, which is concentrated on the theory of how an.

K

Organisation might be running, looking at the policies, looking at minutes and so.

K

On, is no substitute for talking to patients, for observing wards, for having.

K

An expert view as to the capability of a service and so on.

K

I've also emphasised in my report, something which it appears to me this.

K

Organisation is signing up to in spades,, which is the need to insist on.

K

Institutional honesty and openness.

K

The institutional tendency has been in the past, I fear, to not own up to.

K

Difficulties within, and sometimes in unhappy cases, one would say there has.

K

Been actually covering up of, or concealment of serious information.

K

And, along with Sir Ian, Kennedy, and many others I feel that quite often the.

K

Cover up the concealment of information is actually a far more serious matter.

K

Than whatever the original deficiency was in the first place, deficiencies can.

K

Be cured, but they can only be cured if we know about them and everyone talks.

K

About them, and the tendency not to do that must be resisted at all costs.

K

Part of that is the need to share all potentially, and I underline the word.

K

Potentially relevant information with all those who can actually do something about it.

K

One of the quite astonishing, to me, findings at Stafford was the way in.

K

Which this organisation's predecessor and Monitor seemed to have a different.

K

Set of information and therefore were not working together on the same basis.

K

And that led me to make recommendations which haven't.

K

Necessarily met with full favour about how the operation of those functions should change.

K

But, however, those functions are to be performed and taking up a point really.

K

That was made earlier here today,. It seems to me utterly essential that there.

K

Is joint action to avoid duplication,, to avoid overlap,, to avoid gaps and to.

K

Maximise effective patient protection and that really does require a very clear.

K

Idea of what the job of each organisation is in this terribly complicated system.

K

And, then, to find a way of making sure patients and the public don't have to worry about that.

K

You shouldn't have to write to one organisation and be told it's not our job.

K

And then be told to write to another one, which says: actually it's not really ours.

K

Either, to write to a third which then takes four months to tell you that.

K

Something can't be done for another reason.

K

You should be able to write or contact any organisation in the Health Service.

K

And they should automatically,, the matter should be referred to, whoever it.

K

Is who is able to deal with the problem.

K

Is that possible? I don't see why it isn't.

K

One thing is clear: it seems to me, I'm sure you would all agree with this in this.

K

Room, is that the regulation in itself cures nothing.

K

On the whole regulation is there I think, to deal with things that have gone.

K

Wrong, but it can't necessarily stop things going wrong in the first place.

K

And, we have to recognise the need for efficient, conscientious and committed.

K

Leadership at the level of providers of healthcare services and, of course,.

K

Social care as well,, without that no regulation in the world will keep patients safe.

K

So I'm sure it remains,, whatever I, say about looking at individual cases and.

K

Real patients and so on,, it must remain part of your task to have a view about.

K

The effectiveness of management and leadership- and you know, I- have a fair.

K

Amount in my reports to say about that and I'll try not to say too much more about it. Today.

K

Two other points about monitoring of organisations,, one which is not always.

K

Comfortable for me to say,, bearing in mind part of the role of your new chief.

K

Inspector,, but we do have to guard,, it seems to me, against using overall.

K

Ratings as actually being a complete reassurance that everything is right in an organisation.

K

I, as a patient,, if I'm going to a hospital,, might be interested to know whether on.

K

The whole it's good or it's outstanding.

K

But. What I really want to know is if I'm going there to be treated for cancer, is.

K

How good are the doctors there who are dealing with cancer.

K

If I'm going to have my appendix out I, want to know how good the surgeon is.

K

Who is likely to undertake that. If? My mother is going into a ward for the elderly, I, hasten to add she's not,, but I.

K

Want to know what the infection rate is on that ward, I want to know how the.

K

Performance of that ward compares with other wards.

K

Now I don't need to be able to read all that information. All the time,.

K

But I do need that when I need it.

K

And to disguise some of these,, the potential failings in smaller units under.

K

An organisational rating is I, think not what's intended,, but we have to make.

K

Sure, that's not what happens.

K

And! That leads me to a final point before going on to something,, if I may say about the Care Quality Commission itself.

K

Which is that in Stafford as I think in a number of other places, we now know,.

K

There was too much reliance on the external assessment of it as being.

K

Confirmation that everything was all right, as an abrogation of the.

K

Responsibility of the local organisation to be examining itself and using its own governance, systems.

K

And, so I would ask you to ensure that whatever assessments, you publish.

K

About places,, particularly when they're good, and you should, of course, publish.

K

And praise good practice where you find it,, that that is not used as an incentive.

K

For local leaders to rest on their laurels, because clearly that is dangerous.

K

Can I just reflect a little on what I see here at the Care Quality Commission?.

K

Firstly to say, I welcome the approach that's been taken to exploring how a set.

K

Of fundamental standards might be created, and, to my mind, it is essential to.

K

Find what it is that brings the public and the providers and professionals together.

K

In agreement about what it is, that must be provided in every case of care,.

K

Without which that care should be regarded as unacceptable, or intolerable.,.

K

And I think we need therefore to find something, and it is difficult and I don't.

K

For a moment, resile, deny that, to find some way of expressing these things in.

K

A way which all people, patients, public, nurses, porters,, even Chief, Executives,.

K

Can understand. So that all can see whether or not that is being delivered and, of course it has to.

K

Be phrased in a way that it is capable of being complied with in accordance with.

K

Whatever the necessary guidance, is.

K

And, actually it needn't be standards which cover absolutely everything that is done.

K

But they are things which would be common to every form of care.

K

And, they should be things that are so seriously required that where they are.

K

Not,, potentially serious and proportionate consequences should follow, and I don't.

K

Think I need say anything more about those here. Today.

K

Candor, as I have already said, I believe is absolutely essential and you should.

K

Insist on it and what are and what should be, the regulatory consequences.

K

For failure in that regard is a matter for you,, but the question I would ask, is.

K

Whether a provider that is not candid with patients whom it has harmed,.

K

Can that provider in fact be regarded as a safe organisation?.

K

I rather doubt it.

K

Finally, can I turn to your role as a role model?.

K

I didn't think when I started my second inquiry, it would be my job to spend a.

K

Great deal of time actually examining how the Care Quality Commission worked.

K

That turned out not to be the case.

K

And the evidence that I received did suggest that at that time a culture.

K

Existed in this organisation, which was an unhealthy one, and I, don't hesitate to.

K

Say that in this building.

K

There seemed to me to be evidence that there was a fear to speak out.

K

Sometimes about quite reasonable concerns.

K

There was evidence of a hostility towards those who did.

K

There was perhaps a preoccupation with setting out the good news story, rather.

K

Than a balanced picture.

K

There was an approach to regulation in terms of standard and enforcement.

K

Which had problems? Which weren't really being addressed, and not all by any.

K

Means of the Care Quality Commission's own making,. It was.

K

Challenged by having immediate demands made of it over a huge range,.

K

Wide field of responsibility, which actually made being effective in any of those.

K

Fields really very difficult indeed, and that was compounded- and this is so often.

K

The case with reorganisations at a national level in this country, as far as I.

K

Can see, there was a lack of an effective means of hand over from its predecessor.

K

So, that was not a very happy picture that I saw.

K

But I believe that it was a picture that actually provided this opportunity,. This.

K

Organisation with a huge opportunity in transforming itself into actually being a.

K

Role: model, organisational role, model for the rest of the Health Service,, because.

K

Many of those features that I just described were there at Stafford.

K

They, are there I'm afraid in other parts of the system and in other Trusts.

K

So I welcome many of the developments that I now see. Happening.

K

I welcome the demonstration of a commitment to openness,, albeit.

K

Sometimes, when it's very uncomfortable for this organisation to do that,.

K

And you've been discussing some of those things here. This morning.

K

I welcome the report about the staff experience in relation to being bullied,.

K

Which has recently been published.

K

And? These are positive, developments.

K

I think the way in which the fundamentals of care are being.

K

Considered openly and with the public is really good.

K

I think that the development of an expert inspection regime under your.

K

Chief inspector also sounds very promising. Indeed.

K

And, the recognition of the need to examine services and partner.

K

Experience as well as the organisation as a whole,, as I've already said, is.

K

Important and welcome.

K

What am I still looking for? Well I wonder what it is is going to be the route to immediate enforcement.

K

Action to safeguard patients, where perhaps consensual action is unlikely to.

K

Suffice,, in other words, an inspection, finds something that is immediately.

K

Required to be done to protect patients, at the moment, if I understand it correctly,.

K

It requires consent to do something, otherwise you have to get Monitor to.

K

Enter into the fray and how long will that take, is a somewhat movable feast,, so I.

K

Wonder what action can be done there to enhance the ability to take immediate.

K

Steps where those are required?.

K

I would like to see,, and it may well exist, evidence of the common understanding.

K

Approach and where necessary, joint action, between the Care Quality.

K

Commission and Monitor,, given that they will continue to have separate roles.

K

There is an issue I think about where individual patient cases are going to be.

K

Dealt with, when they show a potential regulatory, breach, and I think there is.

K

Some potential level of uncertainty there.

K

But I think on the whole, if I may say so, and I'm glad to be able to say so, there.

K

Is the potential for the Care Quality Commission to actually be? Firstly, a role.

K

Model for how an organisation should run itself and how a culture can be transformed.

K

And I think there is the potential for it to become the,. Firstly, the, not only the.

K

Policeman, if you like, but also the lighthouse,, the warning,, the beacon that.

K

Warns of rocks ahead, and enables and actually motivates people to make the.

K

Relevant changes, so by communication of information, by effective inspection.

K

And by the incorporation of professional experts into the work you do, I do think.

K

That insofar as regulation can make a difference, and it can, I am hopeful for the future.

K

Thank you very much for listening to me.

A

≫≫≫ Thank, you very much Robert, any questions for Robert?.

A

C

≫≫≫ Thank you. Just. Firstly, to say that I also feel optimistic. That CQC is changing and will.

C

Change,, both in terms of the approach and the culture,, so I think there are.

C

Definitely reasons to be optimistic and I wouldn't have stayed if I didn't think that.

C

A couple of things, one is that we as a regulator, we have said we are on the.

C

Side of the patient and that's absolutely right,- that's indisputable,, but I'm also.

C

Conscious that in doing that,, potentially we become quite divisive and that we.

C

Say, because I know we're not saying this,, but just thinking of staff working in.

C

Services, because potentially we're saying we're on the side of the patient.

C

And so you're, not on the side of the patient.

C

And I know there's a move to look at consumers, patients as consumers and.

C

There's a lot of benefit in that,, but it's also different because the staff working.

C

In services are there to care, and so I think we need to be mindful of what we.

C

Do and how it is experienced by them generally and specifically.

C

And the morale in services at the moment is quite low actually,, but at the.

C

Same time there are green shoots.

C

I see some organisations looking at Mid Staffs and the Francis Report as a real.

C

Opportunity and some people really have got hold of that, and that is to do with leadership.

C

But I'm conscious that, particularly with the change in the system, and the.

C

Financial situation, where cuts are beginning to bite, that we absolutely.

C

Must put safety first,, but we do need to consider carefully I think, how we work.

C

With people in services,, frontline staff, and managers and chief execs actually.

C

Because you can see that they are actually being given an impossible job at times.

C

So, it's something that we need to be aware of and I just wanted. Your take on.

C

That, because it can be criticism,, criticism,, criticism,, more cuts, and how.

C

As a regulator, we could, yes be on the side of the patient,. Yes, take action and.

C

All that, very, very important,, but also to be mindful of the wider context.

C

Because, ultimately, that also will impact on patient care and safety.

C

The other thing is that, in one of your recommendations, Robert, I think you.

C

Suggested a Patient's Council, and we're looking at developing what we're calling a People's Panel.

C

And, we already have quite a lot of involvement of people who use services.

C

In our inspections and all sorts of things, which I actually think we do quite well.

C

And we need to do more, of. But, what we haven't really done so far is, the people that are involved are like.

C

Expert patients, if you like, and they have a very valuable contribution,, but what we.

C

Haven't got a way of doing effectively, and I know it relates to Healthwatch as.

C

Well, is ordinary people in the street, you know.

C

As, you know, I've become a convert to Twitter and I, get endless things. Tweeted.

C

At me, individuals, people currently detained in a mental health, ward or.

C

Someone who's just lost their son in a treatment unit, and it's getting that,. It's so valuable.

C

So, the People's Panel is one idea that we're thinking about how that should.

C

Work,, should it be huge or should it be a few,, but alongside that,, how do we get.

C

To the individual members of the public actually, who are not involved and don't.

C

Know the health and social care system, because most of the people we have.

C

Involved at the moment are sort of expert user patients.

K

≫≫≫ Well thank you. Firstly in relation to your first point, absolutely,. The staff of the NHS need to.

K

Be respected,, valued and supported, and in most service industries, retail, for.

K

Instance, the most successful ones are those which do precisely that.

K

There are two points about this I'd like to make..

K

The first is Care Quality Commission, as the role model, clearly has, and indeed I.

K

Think if I may say so through your continued presence on the board,.

K

Has evidenced proper conduct in relation to the respect to be given to people who raise concerns.

K

That should be welcomed,, not vilified.,.

K

And I think that is a strong message that this organisation can give to provider.

K

Trust and others in relation to concerns that staff raise.

K

And, this organisation therefore has a role to play in supporting hospital and.

K

Other staff who raise concerns within their organisations.

K

And one way of doing that is to evidence the fact that, when concerns are raised.

K

Something is done about them.

K

And, the widespread reason,, a widespread reason, or any survey will tell.

K

You, why staff are reluctant to come? Forward, is because they don't believe.

K

Anything will happen if they do,, apart from, of course, being vilified.

K

So, in both those respects, it seems to me this organisation has a very valuable role to play.

K

But it has another one.

K

There has been much debate about my recommendations, around guidance.

K

About staffing, levels. So much of what goes wrong in our hospitals is likely,, and indeed, to be fair, it.

K

Was in many regards the case in Stafford, due to there being inadequate.

K

Staff,, either in terms of numbers or skills.

K

And the evidence given to my inquiry was not such as to persuade me.

K

However, that there should be a minimum across the board, staffing level,.

K

And I know not: everyone agrees with that conclusion,, but I can only act on the.

K

Evidence I had and I was, after all, only dealing with the events arising out of a particular hospital.

K

So, the inquiry, for all its breadth, in the end had limitations.

K

However evidence has been put forward to me, certainly since from the safe.

K

Staffing alliance, to suggest that there is a level below which it should be.

K

Regarded that a service is not safe., Not that that's the adequate level of staffing,, but it's the level below which.

K

You cannot be safe.. Now I haven't evaluated that evidence.

K

I, don't know what anyone thinks about it.

K

But, it does seem to me that it's evidence that's worth consideration and therefore.

K

Ought to be considered somewhere with regard to whether there is some sort of.

K

Benchmark,, whether you call it a standard or whether you call it something else,, which at least is like mortality, rates,, an alarm bell,, which.

K

Should require at least questions to be asked about whether it's possible for a.

K

Service to be safe, given whatever the staffing situation, is.

K

And I just ask you to consider that as being a potential way in which to show.

K

Real support for staff,, some of whom are working in extremely challenging circumstances.

K

On your second point about patient involvement.

K

I think this is one of the really big challenges, is how to obtain the voice.

K

That we need to listen to from patients.

K

And. There is, of course, no one answer.

K

And I think the wider. The range of measures that are taken, the better.

K

Chance there is of capturing the patient voice.

K

Every form of patient involvement, I was told about in the past, the predecessors.

K

To Healthwatch, except the Community Health Council, which seemed to receive.

K

Universal praise,, if only for nostalgic, reasons,, hasn't worked, and the reason.

K

They haven't worked is that far too much is expected of "the public" in the sense, if.

K

You put them in a room and give them a title. They miraculously become a.

K

Coherent organisation, which produces a useful contribution to the debate.

K

The public should not be required to do that.

K

I'm, not saying don't, try, methods of that nature.

K

So all I can suggest is in addition to methods such as you take,. You need to.

K

Perhaps go out there and talk to people on an ad hoc basis as well, encourage.

K

Them to come forward and be approachable and whether sufficient.

K

People even now know who the Care Quality Commission is, how they can.

K

Get in touch with you is debatable, and who can blame them?.

K

I, don't know, I haven't seen Anna's route map,, but if it's anything like the one that.

K

Was in the National Quality Board's first report, it looks more like -- would look.

K

More like a load of wagons being circled by the Apaches than anything that one.

K

Could understand as to how you actually sort out a problem in the Health Service.

K

So I think there needs to be, from the public's point of view, simplification.

K

And part of that is go and talk to anyone, they'll, make sure the concern gets to the right place.

K

But, there are all sorts of methods you can use,, but you need to use lots of them.

L

≫≫≫ Yes I had lots of points,, but I'll try and be very brief.

L

Just on that point, I hope we're already working with the third sector, because.

L

The Patient's Association ambassadors, Carer's UK ambassadors, Alzheimer's.

L

Society,, all these organisations already have routes into the frontline and.

L

Experiences,, we don't need to reinvent the wheel,. We just have to find a way of.

L

Making sure those people can feed in to us from time to time,? That's not the total.

L

Answer,, but it's part of the answer.

L

I just wanted to pick up on two points you made. Robert.

L

One was about the need to avoid duplication and in this vast landscape of.

L

Quangos I do think that is a huge issue.

L

I just,, the Care Quality Commission, is obviously trying very hard to actually.

L

Reduce the number of indicators and the amount of data that will be required,.

L

But when you go around the NHS and social care,, what is so striking is that the.

L

Individual lives of frontline workers are made so much worse by the amount of.

L

Paperwork and the amount of endless time people have to spend filling in forms.

L

So I just hope we can bear that in mind,, because I really think the worst thing we.

L

Can do would be to,, not just us, but obviously Monitor and TDA, and so forth,.

L

The danger is that the response to your report will be a massive data gathering.

L

Exercise that ends up being counter productive for those people who are actually trying to do a good job.

L

The. Other point: I wanted to make,. Following on from what Kay said, really,.

L

One of the most powerful parts of your report was really explaining and.

L

Describing the culture and putting your finger on the essence of that problem as being culture.

L

And, obviously there is a limit to the extent that a regulator can, as you say,.

L

Spot problems in advance.

L

And I just wanted to know what you thought really about the psychology?.

L

Because clearly, as I think Kay was implying,. We need to be very clear and.

L

We need to have punitive action if necessary,, but we also need to make.

L

Sure that people who are trying to do a good job are not forced into a defensive.

L

Position because that will only lead to more cover up.

L

And I, just wondered, I'd love to hear a little bit about your reflections on the.

L

Psychology,, what happens to people who are actually intending to do a.

L

Perfectly good job and end up as some of the people you found, some.

L

You described so well, existing in their own silo and ignoring what was going on.

L

Around them and whether you think there are any insights from that that we.

L

Should be using and Mike should be using when he is trying to effectively.

L

Build a new culture.

K

≫≫≫ As, you say a few challenges. There.

K

I agree with you about using the third sector,, but I think you need to do more.

K

Than that,, and the reason is that, by definition, the third sector,, which is.

K

Absolutely valuable on the whole will be skewed towards a particular point of.

K

View,, quite legitimately, but there needs to be more than that.

K

The bureaucratic burden,, I couldn't agree with you. More, and I have made.

K

Recommendations,, as indeed has virtually anyone who ever comes into.

K

This field will do, about the need for coherent information management with.

K

A view,, if possible,, to ensuring that one entry by a clinician is used for multiple.

K

Purposes, rather than having to employ an army of people to reinterpret the.

K

Clinician's entry into a code which is then open to manipulation, unreliability.

K

And all the problems that we know about and can we please have a joined up,, not.

K

A massive mega system,, even within the hospital,, a joined up information system.

K

That allows patients not to be asked the same question 15 times and the same.

K

Entry being made 15 times by different people,, all those things seem to me to.

K

Be quite capable of being changed and in some places, are.

K

And, so I would urge you to use what influence you can in that regard,.

K

But I absolutely endorse the idea that we should be very careful about what.

K

Information we ask for- and there needs to be, if possible, coordination across the.

K

Quangos to ensure that they have a common set of information and I, don't.

K

Think that's in the end will be too difficult.

K

So far, as the psychology point is concerned,, there are lots of answers,.

K

None of them sufficient in themselves.

K

You talk about defensiveness and there is clearly that danger, that people, when.

K

Faced with a threat of being found to have committed a fundamental,.

K

A breach of a fundamental standard, or whatever it is,, rather than owning up to.

K

It, cover it up.

K

And, that's one of the reasons. I have said that the cover up in many cases.

K

Should be regarded as much more serious than the original deficiency.

K

I, don't think we must shy away, however, from the concept that there.

K

Will be occasions when there should be accountability,, possibly sometimes.

K

Criminal accountability for cases of a serious breach leading to serious consequences.

K

One would hope those would be very rare, indeed.

K

And we talk about defensiveness,, we have a system already, which requires.

K

Under their codes of conduct, professionals to be open and honest in.

K

Very difficult and challenging circumstances and the potential.

K

Penalties for not doing so for them are very serious.

K

No, one to my knowledge has suggested we should take away the GMC and the.

K

Nmc's powers to strike off people who fail in their duty of candor towards patients.

K

What I do think we need to do, however, is: firstly, we actually need to do more to.

K

Celebrate and motivate the people who do come forward in these circumstances,.

K

And to ensure that in most cases that they are praised for doing that, rather.

K

Than ending up being got into trouble for it,, because it's much more important.

K

To have the information than it is in reality to do something negative about that individual.

K

Sometimes, it will be necessary, if safety is at risk.

K

But I think -- I, hope I'm understood of having recommended in terms of.

K

Sanctions, things which actually seek to deter people from preventing other.

K

People from doing the right thing,, if I, can put it that way,, so sanctions against.

K

Harassment and victimisation of whistle blowers, sanctions against people who.

K

Obstruct that sort of endeavour, by, for instance, destroying documents or.

K

Matters of that nature.

K

But, none of these things answer your question. In full,, you talk about silos,.

K

And what happens, it seems to me is a gradual and erosive process in a place.

K

That's not working very well. And for a time,, however weak the leadership is,. However poor the staffing.

K

Ratios, are, people will struggle on and they will keep their idealism and go the.

K

Extra mile, because they came into the service in order to help patients,.

K

But eventually things crack and they can crack for all sorts of reasons,. But one is.

K

I'm not listened to, I really can't do this job.

K

And, therefore, in order to cope with the potential inhumanity, they see around.

K

Them, they go into their own individual silo and stop looking around them, much.

K

Of what happened at Mid Staffordshire could not have happened or continued if.

K

Doctors and nurses had actually looked through doors, seen a patient in their.

K

Own, lying in filth and said this is not acceptable, I, don't care how long we.

K

Have to stay on at night,, something must be done about this.

K

That anger,, which I'm sure we all now feel that patients were left like that,.

K

Somehow left people.

K

And I believe that compassion,, although everyone starts off with compassion, can.

K

Be crushed out of people by a system., And I do believe, funnily enough that you can actually measure that,, not measure.

K

It, but you can assess it,, you can smell it. If you go around in the ward and I think.

K

Inspectors perhaps,: we need to consider how inspectors look at that.

K

But, what happens then, is isolation, instead of actually reaching out and.

K

Asking for help, people turn in on themselves as do organisations,. They.

K

Turn in on themselves and pretend to the outside world everything's, absolutely fine or normal.

K

And, the same thing happens on an organisational level, as it happens on an individual level.

K

So you need as many ways as possible of seeking to prevent places. Turning in.

K

On themselves and becoming isolated, and we can do that through peer review,.

K

Clinical networks, making sure that staff are continually being, not circulated out.

K

Of departments, but circulated into contact with people from outside, so that.

K

They have a means of finding out what's going on, outside, importing it into their.

K

Organisations,, but also telling other people about their concerns.

K

Just, to give an example about where there should be more informal, reaction,.

K

The Senior Registrar in A & E, who went to his college meeting and described to.

K

Them what was going on in the A & E at Stafford,? What happened then?.

K

They all expressed concern,, they all expressed sympathy,, but there must.

K

Have been senior colleagues there,? What did anyone do about it?

K

Nothing,? Oh, that sort of thing goes on everywhere.

K

If professionals in this field decided to get together and help each other. Many.

K

Of these problems would be sorted out long before they ever got near your.

K

Organisation, and I do believe that there is something about the commitment that.

K

Comes with professionalism that somehow needs to be reinforced as the.

K

Real means of ensuring that culture does not slip into this dark place that they have.

K

That's, not a complete answer,, but it's some of my thoughts around this.

A

≫≫≫ Michael did you want to comment on this?.

A

You looked at this concept of a just culture, a bit which might be interesting.

A

You need to press your button, actually.

D

≫≫≫ I think colleagues will have seen in one of David's letters to CQC staff.

D

That referenced, something called the just culture or a just culture.

D

I never actually, embarrassingly, heard about this before.

D

So I Googled it and, of course it turns out that there is a huge amount about this.

D

And, it actually originated in aviation,, which of course is another sector in.

D

Which safety is absolutely paramount.

D

And the central idea of just culture, David, correct me if I'm wrong,, because.

D

David attended a presentation on this, is that it's a culture in which worry is a good thing.

D

And, a positive or a true just culture is a culture in which maybe whistle blowing.

D

Is not quite the right term,, but raising problems is the sign of a healthy culture,.

D

As opposed to the sign of a problematic culture.

D

But it does, to take Robert's point,, recognise that there will be decisions.

D

Taken which are completely unacceptable,, unprofessional, or just.

D

Simply completely flawed, and those need to have consequences, and some.

D

Kind of punishment may not be the right term,, but something has to happen as a.

D

Result of those decisions,, so it has a sort of a gradation of how to react to actions.

D

In a system designed to promote safety.

D

And I was actually very taken by the idea of a just culture and part of the result of.

D

Googling is it turns out that some very important,, apart from aviation, I, think.

D

What would to the outside would be world leading hospitals like the Stanford.

D

Medical Centre or Stanford Hospitals, have adopted a just culture.

D

And I think the Harvard Medical School now teaches just culture as part of its.

D

Programme for training, doctors.

D

And, it may be that one of our next meetings that David perhaps could take.

D

Us through the presentation that he saw on this,, although there is, as it happens,.

D

When you Google, a sort of a standard presentation which I sent to David,.

D

Which the creator of a just culture, gives.

D

And also building on Camilla's, idea, I think as part of the inspections, and I'm.

D

Sure Mike is doing this, some sort of culture audit,, and that is a terrible term,.

D

But I think we know what it means, should be. An important part of an.

D

Inspection of a hospital.

D

And, it may be to take Kay's point, that the culture audit is something in which.

D

Either expert patients or members of the community should perhaps be.

D

Particularly good at being able to understand, I, don't know.

D

But I do think this idea of being more certain that the culture is right,.

D

I feel is important to the inspection process going forward.

D

Now I actually had a particular question for Robert,, which I hope we've got time,.

D

If I can just ask it? And, it's really, I'm asking it in this new role of mine and new role, I suppose of.

D

Colleagues around the table,, which is about non-executives,, because Robert.

D

Made I thought a very important point.

D

That, the non-executives in Stafford had an idea of the borderline between.

D

Non-Executives and executives, and were concerned about overstepping.

D

That border,, and perhaps the executives, influenced this idea of where the borderline was.

D

So I'd be very interested in Robert's reflections on that, and I. Don't expect.

D

Him to say where the border is here at the CQC,, but I think it would be very.

D

Helpful guidance,, certainly for me, to get a more understanding of that.

K

≫≫≫ Thank you. Just a word if I might about just culture, I, of course had a seminar on culture and.

K

Culture came into a number of our seminars and what you say about the.

K

Aviation is also I, think true of the nuclear industry.

K

And we had a talk, presentation from the Chief Executive of a large nuclear.

K

Company, who spends a lot of his time talking to junior staff on the floor of.

K

Nuclear plants, hearing what their concerns are,, welcoming those.

K

Concerns and ensuring what he does about them is communicated back.

K

If he finds it's unfounded. He still thanks them and explains why it's unfounded.

K

Retail is the same.

K

One reaction. I got in the room from,, unfortunately, I can't even remember.

K

Who it was,, but he was clearly a relatively senior figure in the national.

K

Health Service was it's all very well talking about selling televisions or that.

K

But the NHS is different.

K

And. The answer, of course, is that it's not different.

K

If you're in the business of saving lives and making people better. Then the least.

K

It seems to me you can do in relation to your culture is at least do what they do.

K

When they're selling a television set,, you may need to do rather more,, but it.

K

Doesn't -- there is this culture in the NHS that we are different,. We know.

K

What we're doing, we're special and that I fear needs to change.

K

And can I just mention, in terms of cultural audit, you're right,. There are I.

K

Believe various people developing tools which might be used and one of them.

K

Has been developed by a group of nurses called the cultural barometer,.

K

You might want to think about measures of that nature.

K

Turning to your point about non-executives, you're, right that what I.

K

Found was, to my mind, a quite astonishing rigidity,, whether more rigid.

K

In retrospect than it was at the time, I don't know,, but in retrospect to explain.

K

Why various things weren't looked at.

K

Between, what they regarded as strategic, which is what a non-executive.

K

Director could concern themselves with, and operational,, which they couldn't go near.

K

So reports on an individual incident of a patient death caused by systemic.

K

Failings would not get to the board because it would be considered to be.

K

Operational and not strategic, and that seemed to be perfectly all right so far as.

K

The chair was concerned. So there is,, whereas of course, even if you do take that division and one can.

K

See some sense in it in theory,, what is operational one day can become.

K

Extremely strategic, the next, if it can bring down your organisation.

K

So you need, on every case. It must be a matter of judgment.

K

So, firstly, I think I would suggest if I may,, you need a discussion about what it is.

K

The remit is,, but whatever that remit is make sure there is some flexibility there.

K

Judgment about the flexibility must be on the side of the non-executive.

K

Directors, not on the side of the executives.

K

The second point is I, think a matter actually of expertise and many, I'm not.

K

Going to talk about this board,, but many boards of NHS, Trusts and Foundation.

K

Trusts on the non-executive side, quite understandably, have a lot of people who.

K

Come from a business background or people who, for whatever reason, really.

K

Understand balance, sheets, accounts and so on,, so it became much easier for.

K

Them to talk about money than it was for them to talk about the ethereal business.

K

Of quality,, particularly in fairness to them at a time when quality was a brand new.

K

Concept in the NHS and no one quite knew what it was anyway.

K

So there is the fact, it's easier to understand a balance sheet of money.

K

Than it would be, a balance sheet about quality would mean that they would contribute I, think more in that field than the other.

K

So advice, I would give certainly in relation to NHS. Trusts would be please.

K

Make sure that your directors,, insofar as they don't have expertise in these fields.

K

When they come and they may well not, that they get sufficient support to.

K

Understand these rather more ethereal novel concepts and how they can.

K

Contribute in the challenge required on those matters.

K

And the final point- is, I've learned this to my benefit through many years of being.

K

A barrister,, the fundamental rule in almost any sphere, is, do not be afraid to.

K

Ask a stupid question, because almost invariably it's not stupid, and it's not.

K

Stupid, if you need the answer to it.

K

And, if you don't get an answer,, carry on asking the question,. That would be.

K

My tip to any non-executive director.

H

≫≫≫ I was very struck by what you said, Robert, about the opportunity for CQC.

H

To role model, I'm particularly struck by that, because it's actually it's my.

H

Experience that usually the regulator mirrors the sector it regulates and.

H

Actually, this is a challenge to change through role modeling in a way how the.

H

Sector behaves, and then I was thinking about the centrality in what you say and.

H

In what the Davids were saying and linking up with what Kay was saying of.

H

Putting users, consumers at the heart of that new model, and the importance of listening.

H

And I know that in our thinking about inspection, thinking that Mike's already.

H

Doing, we're talking about how to capture local intelligence from users of.

H

Service, to help inform that process,, but I wonder if we might not take something.

H

That I think you remarked on,, which I think is as being really good,. I also think.

H

Has been a really good thing, is the bullying report.

H

So, if you like what we did with the report on bullying inside CQC, was.

H

Create a listening,, an explicit listening, environment.

H

And I wonder whether there isn't something that we can take from that as.

H

A bit of good practice, if you like, and take into our inspection activity,, perhaps.

H

Not just for hospitals but kind of in the round,, because people's experience is in.

H

The round, and think about how we could ask CQC inspection teams at local.

H

Levels to create listening events in order to pick up what's happening, as a matter.

H

Of routine,, not just when they're going into a particular --, but just to create that.

H

Intelligence, I wonder if we did those sorts of things, it might not rub off on.

H

The rest of the system, because I think you'd find that the other providers would.

H

Want to come and listen too, if you were organising it, and it might have an.

H

Immediate impact before we needed to go in to inspect,, but this notion -- I'm.

H

Sure there are many other examples, but this notion we think: how could we do.

H

Things differently, both in our own activity at a national level, but also.

H

Through the inspection regime and challenge the way other people are doing, this I think is really,. A powerful idea, immediately made me think of one.

H

Thing but I'm sure there are many others.

A

≫≫≫ Thank, you Anna, anyone else,. Would you like,? Yes, David?.

M

≫≫≫ (inaudable) because it was mentioned last time to us that possibly.

M

Members of the public could contribute also because you've encouraged us to.

M

Ask stupid questions. I hope this is one.

M

I'm very interested in your idea that we should get away from generalist.

M

Inspections, CQC should get away from generalist inspections, that is to say, if.

M

You mean by that looking at, in the files, finding a policy which says the good.

M

Care happens and then assuming it does happen,, which does seem to be.

M

Happening to some extent. What I'm, worried about is the concentration on users which may work.

M

And has worked in Morecambe Bay,, but in the, for home care,. Your own report.

M

Which I think you commissioned, excellent report, makes it very clear that.

M

A lot of older users and dementia users find it extremely difficult to make a.

M

Complaint or tell the truth,: maybe they don't even know what the truth is about.

M

The care they received.

M

And I think particularly in the area of home care,. There is evidence out there,.

M

Particularly in the monitoring reports, and in the time sheets,, which will tell.

M

You a certain amount about quality, about things like timing,, missed, calls,,.

M

Changes of carer, and maybe give you some sort of indication of what might be.

M

Happening in the other things which can't be monitored in this sort of way.

M

And I would hope that the CQC might pay, so far. I found a certain reluctance,.

M

But should pay rather more attention to using every bit of evidence of this kind,.

M

Where user feedback is so difficult,, so unreliable and so hard to get.

A

≫≫≫ Thanks very much David.

A

Robert did you want to respond to that?.

K

≫≫≫ Well I can't, in my capacity as Chairman,, respond to the business.

K

About home care, although that's a hugely important field and clearly needs.

K

To be considered but I think I can say something about vulnerable patients.

K

Of course, whether it be in hospital, in care homes or at home,, there is this.

K

Vast population of vulnerable people, who really can't speak for themselves,.

K

And many unhappily don't have families who can speak for themselves, and one.

K

Of the thoughts that came from witnesses at Stafford was, in relation to.

K

Sitting there dealing with their own families, brought outpatient's relatives.

K

Problems with the care, what's happening with those that haven't got.

K

Someone sitting by their bedside?, And I, would urge, I hope I've urged sufficiently in the report that.

K

Consideration is given to how you give a voice to those who can't speak.

K

For themselves and ensure their care is looked at in the same way.

K

As perhaps those who speak more loudly but I agree with that.

L

≫≫≫ Just to say I recently completed a review of care. Workers, I know the.

L

Department of Health was looking at whether you can introduce a friends and.

L

Family type test for those people and of course there are, as you said,.

L

Very big issues,, partly when do you trigger it, because it's on-going.

L

Relationship, people are nervous about making a complaint,, but the other thing.

L

That struck me was that you can get a lot of information from home care workers.

L

Themselves, and from Unison, the unions,, that's just a point: really.

L

That I think if we across the board are going to be better at hearing from staff,.

L

We might just want to think about. That. There are about half a million people who work in that sector,, some of whom.

L

Are constantly moving between agencies and some of whom actually give you.

L

Some quite good insight into what's going on.

M

≫≫≫ Hertfordshire Healthwatch, I, wonder Mr Francis. If you could perhaps.

M

Elaborate a little more on the complaints side of the NHS, which you referred to.

M

Earlier and the complexity of the current complaints procedures and somehow.

M

The NHS has an ability to subvert to avoid any changes that come into a.

M

Complaints, procedure. So, we have had,, we have an NHS constitution,, it was revised,, it speaks.

M

Specifically about the need, for example, to acknowledge a complaint within three working days.

M

That is widely ignored by hospitals, I, think, and complaints are, in experience.

M

Of patients are widely ignored.

M

What is it about the culture of the organisation that whatever changes are.

M

Introduced there's some way around responding?.

K

≫≫≫ Well one can say it's. Human nature becomes cultural nature of.

K

Avoiding issues is partly it.

K

But actually I think what I've said in my report about complaints is, firstly, they are.

K

The absolute gold dust in relation to an organisation itself learning what it needs.

K

To do to change,, therefore, any organisation which is ignoring or.

K

Downgrading complaints,, not responding to them properly is almost certainly.

K

Either dangerous or on it's way to becoming dangerous,, that's the first point.

K

The second point is that there should be, in my view,, a greater level of.

K

Independent scrutiny of complaints, and I don't mean by that that this body.

K

Or other bodies should take over the running of the complaints,.

K

That clearly should, in almost all cases remain with the provider,. But firstly, there.

K

Is a category of complaint, where it should become far more routine than it.

K

Is at the moment that the investigation is done independently,, it's unfair. It seems.

K

To me to expect the relevant senior staff on a ward who are implicated in a.

K

Complaint to investigate it themselves,, they won't know how to do it.

K

The next point is: we need transparency about what happens with complaints.

K

Generally,, so local Healthwatch,, the Commissioners and everyone else are.

K

Actually interested themselves,, not only in numbers of complaints,, because.

K

Actually, the more complaints there are, that doesn't tell you whether the place is.

K

Good or bad,, but what's in those complaints and what I found looking at.

K

Complaints was again individual cases or a collection of individual cases can tell.

K

You an enormous amount about what's going wrong in either a ward,, a hospital.

K

Or a service,, so I believe that the stories of those complaints,.

K

Suitably anonymised, should, and you may well need the complainant's.

K

Consent, I don't see why that wouldn't be given in most cases,, but there should be.

K

A publication of those stories, lots of it turns up on websites and so on. Anyway.

K

And I think if you publish those stories, the message gets back to staff.

K

One of the problems, I think is, if you just give staff and everyone else, figures,.

K

And trends, and so on, they don't actually connect all that with the impact it has on.

K

Individual people,, whereas -- and they end up not believing that the complaints.

K

Are serious, that there are people in Stafford who still believe that their.

K

Hospital is being unfairly described in the past, I'm, not commenting on what.

K

It's like now,, but what it was like then.

K

Even, though, they've read these complaints, but I think if we actually.

K

Read what people have gone through,? They would find it much more difficult.

K

And is it impels people to do something about the problem.

K

But, one of the more boring points is those who are employed to deal with.

K

Complaints in many hospital trusts are under valued, under trained and.

K

Generally, under resourced,, with the result that it's inevitable that they breach.

K

The deadlines required,, it's inevitable, that a lot of complaints aren't dealt with very.

K

Well,, because they're not given the priority by the organisation, they should be.

K

This is really important information which can actually end up, meaning the.

K

Difference between patients being treated well or patients being treated.

K

Badly in the future. So, any organisation must be on top of its complaints.

A

≫≫≫ Thanks, time is moving on,, so Paul and Mike both wanted to say something.

A

Then I think we'll probably have some coffee.

G

≫≫≫ Thanks David. To Mr Hogart's point about home care, I think you exposed one of the hardest.

G

Sectors that we have to regulate and you're obviously right about the patients.

G

Who have dementia for example.

G

I think the way we have to frame this, though is, we are probably not going to.

G

Get the fullest picture in that sector, because of the complexities associated with it.

G

But the way we need to then frame it is how much better can we get them.

G

Where we currently are, and progressively better on a journey, I, was.

G

Concerned you've picked up, you've been at a number of our listening events.

G

As well,, there might be a resistance to using our performance, I want to pick up.

G

On that, because we should use other forums if we can't be confident the user.

G

Voice will be in anyway sufficient, but I think it's important for us to make.

G

Progress on this and not be put off by the fact of how difficult it is.

M

G

To Robert,, we had quite a conversation about the role of us as regulators and.

G

Some of the interplay with the other regulatory bodies and also a lot of.

G

Discussion about the providers, I wondered about how you saw our.

G

Interplay with commissioners,, given we have legitimately overlapping, but.

G

Different roles, and particularly the allocation of resources, role that they have and we don't, some of the things are easy, like the transparent.

G

Information sharing,, but some of them are significantly more difficult challenges.

G

And I wondered how you saw the balance of risk and opportunity in the.

G

Way that we choose to work with commissioning boards, CCG's?.

K

≫≫≫ Well, firstly, can I, say I. Think a message from my report would be that if.

K

We have commissioning,, it must be taken seriously and a complaint by a.

K

Patient that they've been badly treated in hospital is in part, a complaint that the.

K

Service that's been commissioned, hasn't been provided,. Therefore, it is a.

K

Responsibility I think of the commissioner to as it were, where.

K

Necessary take up the cudgels on behalf of the patient and I, don't mean.

K

That there is an appeal system and all that sort of bureaucracy,, but to ensure,.

K

Take up the cudgels to ensure that the complainant is being A,. Looked after.

K

Properly, and B, that the Trust is actually doing something about the substance of.

K

The issue that the complaint raises.

K

Now I understand that it may not be practical to do that to provide an.

K

Individual service for absolutely every patient, and there needs to be some sort.

K

Of selection process,, but that could be either dealing with it on a random basis.

K

Or you can grade things,, so it's the serious complaints that you give priority.

K

To making sure are dealt with,, but I do believe that commissioners have a role,.

K

If necessary to intervene in order to insist that the matter is dealt with.

K

Properly,, that's not an appeal,, it's not a revisiting of the complaint,. It's actually.

K

Using their powers as commissioners to ensure the service they have paid for is.

K

Actually, being provided. What, does the Care Quality Commission bring to it?

K

Well? Firstly, the intelligence that exists in the complaint,, the information it seems.

K

To me is again gold dust to the Care Quality Commission, again it doesn't.

K

Mean that you can, David Behan here can examine every complaint throughout.

K

The country,, that's impossible,, but your structure of intelligence, of inspections.

K

And so on should embrace the information that's contained in the complaint.

K

Interaction with the commissioners, share information, and when I was.

K

Saying earlier about assessing all the time, the impact in relation to patient's.

K

Safety of the information you have, applies, particularly, it seems to me to.

K

What you find out in relation to complaints.

K

So in the sharing of information, it needs to be part of the function of the.

K

Care Quality Commission and the Commissioners to be looking at what.

K

Does this tell me about how safe this place, is?

K

And it may be- it's saying this place is actually,. This ward is absolutely.

K

Dangerous this very minute,. We need an intervention,, because if actually the.

K

Intervention took place in relation to complaints, you'd, never get to having to.

K

Be alarmed about mortality down the line,, if you see what I mean.

K

So I can't tell you how you do that,, but it seems to me that's an approach that.

K

Perhaps should be considered.

E

≫≫≫ I'm happy to cover my point in my presentation.

B

≫≫≫ Okay Robert, thanks very much, I've long argued that your report is a.

B

Seminal one and I think the service that you continue to perform by articulating it.

B

Clearly, and simply and thoughtfully, as you've done this morning, is a.

B

Tremendous service to the public, to professionals,, but to us in the way that.

B

You spoke your comments, this morning.

B

I'm grateful for the reflections which are supportive, I'm, equally grateful for the.

B

Reflections which are challenging as well and of this unfinished business, which you've flagged up.

B

I think on the joint work there are meetings this week with both TDA and.

B

Monitor on Friday afternoon, which is pushing into this challenge of how we.

B

Can work with both of those organisations and make sure that we.

B

Have got systems and processes in place to exchange the information and.

B

Actually make these decisions.

B

It's work, which is going with good grace and support,, but it's work that needs to.

B

Be completed and isn't completed.

B

On enforcement,. We need to take that away,, rather than we've got a ready answer to this.

B

It's something we're acutely aware. Of, of what powers we're left with to take.

B

Immediately and what have to be negotiated and agreed,, there is further.

B

Work to do on that and it would be wrong to suggest we've landed, that.

B

Your point about individual cases, which has really gone from 9 'clock. This.

B

Morning to this particular point in time is really something we'll pick up in the.

B

Design of methodologies, I'm convinced we need to speak to people who are.

B

Ordinary service users,, not just the normal groups, which represent them.

B

We do have arrangements with the Relatives and Residents Association.

B

And the Patients Association who get cases on their helpline and refer them.

B

Through to us, if there are systemic issues and we have a contract with.

B

Them to do that and we're considering extending it to the Carers Association to.

B

Get that similar form of arrangement.

B

But. This point that we are speaking to the families in Morecambe Bay is one.

B

That's really landed. I personally think we need to speak to complainants and.

B

Whistle blowers as part of our inspections,, not all of them all the time.

B

But we are looking at how we do that.

B

I love the metaphor about a lighthouse, rather than anything, else, I thought that.

B

Was powerful and to the point and picks up.

B

So Robert. Thank you for that,. What is item 3, David, I'll. Do this very briefly.

B

Which is a report which is a more formal response to the recommendations.

B

Robert made in his report.

B

There are 36 recommendations which were directly to us as CQC and a further.

B

73, where we need to make a contribution, to.

B

The annex goes into some detail of where we're up to in terms of the report,.

B

I'll not present the detail, David, safe, to say what we are attempting to do here is.

B

Identify how this work is embedded into the work we're doing to redesign our.

B

Hospital inspection methodologies and the approach that we're taking, that's a.

B

Transformational change we're trying to make, as opposed to chasing down 109.

B

Separate recommendations.

B

The issue I think we're trying to grapple with here is: how far can the detail of.

B

Those recommendations be embedded in the transformational changes. We are taking?.

B

So, the strategy,, the business plan and the work we're doing around transformation are really the vehicles we're using to take this forward.

B

We'll track every individual, recommendation, David, and we're.

B

Committed to providing a further detailed report in November that will allow that.

B

Transparency with Robert's original recommendations and how we take this forward.

B

We also contribute to a group that the Department's running on patients first.

B

And foremost, because there's a collective agreement, we've entered into.

B

With the Department that we'll support the publication of something in the autumn.

B

Further work on this is I. Think Don Berrit publishes a report next week and we'll.

B

Expect his recommendations on safety for the government to consider and on.

B

This important point: that's resonated through the morning, Clwyd and Herts.

B

And their recommendations,, we understand that's due to be published in.

B

September this year, Paul was making his point at dinner yesterday evening.

B

There is further work. We need to do to consider those recommendations, but I.

B

Hope the board can accept the report, I think it's appropriate. It follows Robert's.

B

Conversation with us all this morning about the progress, we're making.

B

I'm really pleased that this has been webcast this morning, because it can.

B

Then be a record of I think a very clear conversation that you've helped us.

B

Through Robert, and I really hope as many of our staff as possible can.

B

Actually spend some time having a look at the conversation that followed this morning, so David thank you. Thank, you Robert.

A

≫≫≫ David thanks very much, Robert. Thank you very much for coming this morning.

A

I think your report will be the seminal report on the NHS actually because for.

A

So long we've accepted the NHS as an iconic institution that is almost beyond.

A

Criticism and that actually to criticise the NHS, you felt bad about yourself,.

A

But actually, if we don't have the truth about what's happening in the NHS.

A

We'll,, we won't have trust in the NHS, and I think. Paradoxically, the robustness.

A

Of your criticism is the best hope in restoring trust in an institution that we all.

A

Feel very strongly about,, so we hope we can carry on putting into practice much.

A

Of what you said in your report,, so thank you very much, and I think we'll have a.

A

Break now for coffee, thank you.

B

≫≫≫ Thanks David I'll spin through this pretty quickly, first point: I want to pull.

B

Out is with Mike having arrived, I've previously asked to you agree.

B

Delegations and some of the judgments we need to make about actions against.

B

Trusts we're now handing over to Mike, that allows me to step back from those.

B

Decisions and I can then be the first point of any kind of appeals and refer.

B

Them to you as appropriate.

B

Item 2 I'll, just keep out of, Mike will report on that when his report comes up, later.

B

There was a question. Earlier, Steve was raising this about the use of Section 48.

B

Powers, in relation to the Deloitte's report, well because of some changed.

B

Arrangements in relation to safeguarding inspections that Ofsted.

B

Have introduced, the joint inspections with Ofsted have now been stood down.

B

Pending further work that we'll undertake with Ofsted,, but what that.

B

Means is, we need to continue to undertake safeguarding inspections of.

B

Healthcare Services, and in order to do that, we need to be clear about the.

B

Powers, powers, we're going to use are Section 48 powers of investigation,.

B

In order to use these, we are required to consult with the Secretary of State,.

B

We've done that,, he has approved that and what I'm effectively doing here is notifying you that that's the case.

B

This was spotted by my good friend Bryn who's arrived from Gloucestershire.

B

Healthwatch, it's a gathering of Healthwatch people here,. So there was.

B

An amended one that was sent out, so the rest of the sentence, is, great when.

B

Members of the public are correcting your report before they've been considered,. I expect this to be an interim arrangement until CQC.

B

And other inspectorates are in a position to introduce multi-agency inspection.

B

B

Transformation programme, there's a seminar later this afternoon for board.

B

Members, we've updated the Grant Thornton review,, just drawing the.

B

Board's attendance to the further work going on around extending the size of the board.

B

In 7 we've covered in the previous discussion: the fact that people.

B

Opportunities have published their report,, we published it last week on our.

B

Website- and there was media interest in relation to that, I- think Robert's already.

B

Drawn attention to it.

B

What is important is just to pull this out in 7.3 that when I considered this with.

B

Other leadership, colleagues, I, think I went into that meeting. Thinking the.

B

Outcome was an action plan,. What was clear at the meeting that was the worst.

B

Outcome, the right outcome was a conversation across the organisation.

B

With the senior leadership team, making some commitments about how it's going.

B

To behave differently, without going into some personal stories,, there are a.

B

Number of people in that leadership group that were moved to tears because.

B

They felt they had been complicit in the a culture that was difficult for them,.

B

That they didn't feel that they needed to, and was a signal I. Think of some people.

B

Beginning to make personal journeys and personal movements as we move, forward.

B

So, what we're looking to do is create a discussion forum on what is the culture.

B

We wish to create in CQC, by engaging the broader staff and leadership.

B

Community, in that conversation and Hilary and Sarah Hunter will do some.

B

More work, which picks up on the conversation we were having earlier about a just culture and how we move that forward.

B

The thing I'd, add to what Michael said about the just culture is the just culture.

B

Is not a no blame culture,, it is a culture where people accept responsibility,.

B

I think that helps your point. Robert about professionalism and professional.

B

Responsibility,, but it is a culture that accepts that. Sometimes we just make.

B

Mistakes, the issue is distinguishing between human error and people being.

B

Reckless in their behaviour, in the way they actually ignore risk and judgments.

B

That they make,, so that's the key issue,. We want to form that as a piece rather.

B

Than keep it separate.

B

And then, the theme of joint work with others, there's some updates on.

B

Important conversations taking place, which result in memorandums of.

B

Understanding, with the Trust Development Authority,, a practice.

B

Framework with the GMC, which really says, if you're a GMC member of staff,.

B

Or CQC member of staff, this is what you do when you meet these circumstances,, which is helpful.

B

Then work with the Royal Colleges that, David, you and Paul, as well as.

B

Mike have been involved, in,, so good progress being made on that.

B

Then, the last paragraph is just to update you on appointments,.

B

Mike's appointment, which has been much trumpeted but Andrea Sutcliff,.

B

Was appointed and has been at two meetings, this week,, even though she's.

B

Probably not released from her current job until September or October time.

B

Helping us with particular issues,, either with Ministers or in an internal meeting, this week.

B

We interviewed for director of corporate services and we just need to confirm.

B

References prior to announcing the successful candidate for that,, we have.

B

An appointment to make and I'm confident the references will be positive,.

B

Then, tomorrow David you and I and Anna and Professor David Haslem will.

B

Interview for the chief inspector of general practice and we'll be optimistic.

B

There's an appointment to make there, so I think once we have completed that,.

B

That will be six members of the new senior management team, appointed,.

B

And not quite with us, but nevertheless in post,, so we'll go on holidays with a new.

B

Board and a new executive team appointed, thanks David.

A

≫≫≫ Any questions on David's report?.

C

≫≫≫ I understand that the first tranche of the friends and family tests have been.

C

Published I just wondered if we're connected in with that, part one. The.

C

Intelligence, but also how it might be useful to us in the future as part of our surveillance?.

G

≫≫≫ Yep, came out yesterday at 9.30, if I remember,, it forms the central part of.

G

Our intelligence or it will do,, so it was the first three months of data,, a decision.

G

Was made not to publish after the first month, which was April.

G

But, we do also have the year's run of the midlands and the east data, because.

G

They were effectively piloted from 2012,. We just need to use it, it's as simple as that.

G

There is a moderate correlation to things like mortality, by no means 100 percent,.

G

You wouldn't expect it to be.

G

The whole principle, philosophy of this model is not to just focus on one indicator but to pick out the ones that genuinely matter,. My hypothesis of.

G

Friends and Family will be one of the ones that genuinely does matter,.

G

But we need to play it into our model.

C

≫≫≫ So: is it just a case of us using the information,, so we're -- the information.

C

Is just passed on to us and then we,, there's no, in terms of how it might be.

C

Used in the future,, how useful it is, or the actual test itself and how it's used.

G

≫≫≫ I think there are three bits: Kay. There is the part that we get it,. It goes via the information centre if I'm, right and.

G

Then comes to us,, we don't see it before others.

G

But then two other, one. We can then feed into the process and do as to.

G

What's working well and not well.

G

There is a legitimate concern out there as to whether the data collection.

G

Process is sufficiently robust across all Trusts to allow a comparison, and we.

G

Continue to play into that on a national policy level,, the other part, because there.

G

Is the free text box and a lot of people have used that in the midlands and east,.

G

I haven't seen the proportion of people using it yet nationally,. That gives us the.

G

Potential for a very rich source of data which, when we go in and do the.

G

Intensive inspections to really pick up people's positive comments, but also.

G

Concerns about what level in the A and E, and it rolls out for maternity from October.

E

≫≫≫ Just to say, I've seen it in use in the mid land and east on various wards,.

E

And I think our inspectors, as they go around the different wards,. It will be very.

E

Interesting to see have they openly put up what the results of their friends and.

E

Family test are, have they put up examples of free text comments from.

E

Individual ward level,, so that's certainly happening in midlands and east.

I

≫≫≫ I had a question on Hogart too, but do you want me to hold that over to Mike's report?.

A

≫≫≫ Do, you want to do your report then, and then...

E

≫≫≫ Very happy to do my report,. Thank you. David.

E

Just, first of all, to say: I am absolutely delighted to have joined CQC,.

E

It's a huge challenge, but I'm really looking forward to it and already into it.

E

As many people will know. I took up my position on the 16th of July in parallel.

E

With the publication of Bruce Keogh's report on the 14 Trusts with.

E

High mortality and on the same day, the Secretary of State, asked us as CQC to.

E

Start the hospital inspection programme next month,, so no pressure, there!.

E

So, two days later, on the 18th of July, we did publish the approach that we are.

E

Planning to take for the first wave of Trusts and we named the 18 Trusts that.

E

We were going to look at,, you will all have seen that.

E

But in essence,, based on the surveillance model that has been.

E

Developed by CQC, we identified six Trusts at high risk, six at low risk and six.

E

Somewhere in between, and we think that will give us a really good spread to.

E

See how our inspection model works and indeed, how the surveillance model works.

E

The approach that we're going to take, very definitely builds on that.

E

Developed for the Keogh review, three separate steps,, one very important step.

E

Of preparation before we go into any Trust using the surveillance, model,.

E

And looking at that to see what it tells us about is a Trust safe, effective,.

E

Caring, well led and responsive?.

E

But equally alongside that, the local data gathering,, and that will be local.

E

Data that ask from the Trusts, from the Commissioners, from Monitor, TDA,.

E

Healthwatch, anybody that wants to provide us with information at that point.

E

And I think that's where complaints will be one of the key issues we'll want to look at there.

E

And, we won't simply want to look at the number,, although that's a starting point,.

E

But we'll want to look and see whether the Trusts have done any work.

E

On identifying themes in the complaints, have they identified the particular areas.

E

Of the hospital where they seem to be getting most complaints?.

E

How, do they handle the complaints and we'll go into this more when we go to the.

E

Site visit,, who is it that deals with them,? How to what extent -- I previously was a.

E

Clinical director, myself at Guys and St. Thomas' and in general I found the.

E

Easiest way to resolve a complaint was to see the complainant as soon as.

E

Possible,, fortunately, we didn't have very many, but that was certainly my practice.

E

So I don't think it necessarily has to always escalate to the Chief Executive.

E

Of the Trust, if it can be resolved before that.

E

So I think we'll definitely be looking at that and gathering that in the data gathering phase.

E

The second phase of the process is the site visit and we've already said that.

E

There will be both announced and unannounced components to that,.

E

And I think the advantage of the announced component is that we'll be.

E

Able to expect the relevant people to be there, unless there are particularly good.

E

Reasons to the contrary.

E

We'll expect them to have got the documentation ready,, but very.

E

Importantly, it will allow us to hold certain key events. Alongside.

E

First and foremost, a patient listening event,. So if we know that in early.

E

September we're going to go into a certain Trust. We can announce almost.

E

Now, when the patient listening event will be and make that knowledge available in.

E

The local press, so that people can be there.

E

And then, the panel can hear the stories from whoever, in the locality,.

E

Good or bad, that they want to tell us about. What's going on at that, Trust.

E

Equally with an announced component to the visit we'll be able to ensure that.

E

We have focus groups with staff set up and I think these prove to be a very.

E

Powerful part of the Keogh visit alongside the patient events, so I'm.

E

Meeting with junior doctors with consultants, with junior nurses,.

E

More senior nurses,, allied health professionals and I think it is quite.

E

Important to get them in those groups, so that the junior doctors are not being.

E

Heard by the consultants who might write their reference, but they can then.

E

Tell us who really is going on and junior doctors, often know.

E

First of all, they move around the whole hospital,, but they have also moved from.

E

Other hospitals locally in the recent past,, so they can do comparisons.

E

And so they are a very valuable part and we'll have junior doctors on our panels.

E

As part of this, as well.

E

We'll take large panels into these Trusts, part of that is. That means we.

E

Don't have to be onsite so long, we can divide into groups,. Some will go to.

E

Maternity, some will go to A and E, some to the frail elderly, ward, whatever,.

E

But then we'll triangulate and find out what everybody is finding out.

E

We'll always go to certain key areas and we've already listed what we think are.

E

Some of the core areas where the highest risk exists, accident and.

E

Emergency,, the medical emergency, pathway,, emergency, surgical, pathway,.

E

Orthipaedics and trauma, critical, care,, maternity, paediatrics,, we'll also always.

E

Look at end of life, care. But, then, on top of that, we'll be able to go into any other area depending where.

E

Concerns have been expressed either through the patient listening event or.

E

Through complaints, whatever it may be, we'll also always have an unannounced.

E

Component to the visit. But, having had the announced component, we may well have heard.

E

From junior doctors that the problems are on a Friday night or Saturday night,.

E

When the staffing levels are low,, we might choose to go back in on Friday or.

E

Saturday night to see what's going, on.

E

Then, the third phase of the inspection is obviously a report, and that report will be.

E

Ours, and it will in due course, lead to ratings,. We can come back and debate.

E

Ratings but we are committed to giving an overall rating for the Trust,, but also to.

E

Rate, the safety,, the effectiveness,, the caring,, the responsiveness and well lead.

E

I would also like to get down to the level of rating individual services, Jennifer.

E

And I have discussed this many times.

E

Your example of cancer services. Robert, I, would actually say need to go further.

E

Than just saying cancer services,, it's the breast cancer service or the colo-rectal.

E

Cancer service or lung cancer, service, I, know from my previous experience, one.

E

Can be a whole lot better than another in an individual Trust.

E

So, that's the process.

E

We'll no doubt develop this and modify it as we go on,, but through wave one.

E

We have at the same time as the announcement on the 18th, people will.

E

Know that I suggested that we might need a small army of people to help us.

E

With these inspections, I've been extremely gratified by the response.

E

Where over 3,000 people have now responded,, roughly speaking, half.

E

Professionals and half members of the public,, often patients or carers and I.

E

Think what this tells me is that people do want to see the NHS get better and they.

E

Are prepared to help us in that act,, so I'm very encouraged by that.

E

Just before I finish, to say we are taking forward work on mental health as rapidly.

E

As we possibly can. We're starting one stage back because we don't have the Keogh review process to build on there,. So instead of that, what we're doing is co-producing our.

E

Approach with a whole range of different people in the field of mental health,.

E

That is well underway, and some of us met with colleagues at the Royal College.

E

Of Psychiatrists, just over a week ago; there have been internal meetings, there's an external reference group that I will now join, and our plan is.

E

That during the autumn, we'll have our proposed methodology, I. Think a lot of.

E

The principles will frankly be the same,, but the application will be different.

E

Because often mental health Trusts are on ten different locations,, we'll have to.

E

Do things, and the services they provide are obviously different.

E

So, we'll, hopefully go out to consultation later in the year on our.

E

Approach to mental health, Trusts and then early in 2014 I would hope that.

E

We'll at least be piloting inspection and then with the distinct aim of catching up.

E

So there is parity between mental health and acute services in our approach,.

E

With the aim that our first round of inspections of both I would hope would.

E

Be completed by the end of 2015,, we haven't formally decided that, but it.

E

Seems a good objective to me. Thank you.

I

≫≫≫ In, referring to the 11 Trusts out of 14 in the Keogh reviews they are in.

I

Special measures; I just wondered if we're now going to take ownership of.

I

Those 11, does it require a reinspection before they come out, a complete.

I

Reinspection and have we thought about that?

I

And, presumably in the new round, we'll have the same sanction, I'm not trying to.

I

Prejudge any of them,, but in some cases there may be some that go into special measures.

E

≫≫≫ Yes in terms of all 14 Trusts. We have already committed that we'll do a.

E

Follow-Up inspection. Now the exact nature of that inspection we haven't yet committed to, but we have.

E

Said we'll do this within the next year,? What I plan to do is to go back through.

E

The 14 reports and action plans that came out of the Keogh review,.

E

Those actions have timescales against them,, we know who is meant to be.

E

Leading on what,, we can then decide. When is the sensible time within that.

E

Next year, to go back into those Trusts and to see whether they really have.

E

Made the changes that were recommended.

E

So we are committed to that. Yes I suspect that we'll find more Trusts that may need to go into special.

E

Measures, I can't say that,, but it's quite possible, and if so, again we'll be.

E

Working with Monitor or TDA, depending on the nature of the Trust, when we go.

E

Into it,, in terms of that action.

I

≫≫≫ So, the expression special measures is within our existing powers?.

E

≫≫≫ To, the best of my knowledge. Special measures is a new term to the NHS and I. Don't think it has any particular standing as yet other than it's being used..

G

≫≫≫ I think that's absolutely right,. It doesn't have any legislative basis, in the same way that it does for Ofsted,, but what it has meant for those 11 is.

G

That it's -- they're now subject to a governance, review, and I think that's.

G

Important from the way in which we look at them in the future, because we'll be.

G

Looking at their "well ledness",, while Monitor or TDA, will have to first.

G

Complete their governance review and decide whether the senior leadership is.

G

The right senior leadership for the future.

B

≫≫≫ It's, not legal, but if you look at the Care bill,, the Care bill has an escalation.

B

Process of concerns in relation to hospitals and failure to come out of.

B

Special measures when we re-inspect, in the Care bill triggers automatic.

B

Consideration by CQC and Mike on our behalf,, the next step is administration,.

B

So that is a formal process and the Care bill will give legislative event to this.

B

So one needs to look at the language used on these Trusts in the context of.

B

The plans in the Care bill,, where the Care bill has a three stage escalation.

B

Process in relation to failure, in relation to any Trust,, whether they're a directly.

B

Managed Trust or a Foundation Trust.

J

≫≫≫ Two things,, the second I think touches on that.

J

The first is that there is a very,, very large mandate behind these inspections,.

J

It's impossible to over-estimate,. If you look at what was said in Parliament and.

J

If you look in a sense, the direct response after the Francis report,.

J

People will be very interested in what they say and how they say: it.

J

These will be sizable events in the autumn.

J

And, we need to know that as they hit there will be a rhythm as they come out.

J

The second thing is because of that what happens next will become as.

J

Significant as the inspections.

J

And, what happens? Negotiation is not so much in our power, as in the power,.

J

If you look at the, your report, just a couple of items ago, and item 12 about.

J

Strategic partnerships, there's a lot of discussions going on with the TDA, with.

J

Monitor and with others and in the Care bill about a set of outcomes, and before.

J

The first report lands. We need to be clear about what that rhythm is,, because the.

J

Report will be brilliant, note the change from may to will there -- the report will.

J

Be brilliant,, but the outcome of that report is what matters, and we are still in.

J

A sense in negotiation with others about what that means,. What does the TDA.

J

Do,, what does Monitor do,? What do we then do in response to what they do,.

J

And if there is a thing called special measures which then leads to administration,, then that becomes a different sort of road..

J

Robert,, it's a really interesting thing at the moment that it may well be.

J

That Mid Staffs closes because of money,. That's the only administration at.

J

The moment, and so where we have a report around quality,, which shows a.

J

Catastrophic hospital, but it will close because of money, and some way down.

J

The line there will be a closure because of quality, there will be an administration.

J

Because of quality and that's part of the rhythm, I'm, not saying that's the only.

J

Part, but part of the rhythm we need to get into.

J

So this, there will be a lot of expectation on these inspections, but more on the.

J

Things that are as yet unfinished in the system and that all of,, David and Paul.

J

Need to get those discussions with strategic partners really clinched.

E

≫≫≫ Thank you Paul for saying that the reports will be brilliant.

E

I think what I didn't particularly say is that in the third phase,, the report back.

E

Phase,, we are also proposing to hold a quality summit for each one of those,.

E

In the Keogh process this was always called a risk summit, but then he was.

E

Looking at hospitals that all had high mortality- and we hope we'll find some.

E

Hospitals that are really very good,, but a quality summit at which we'll present the.

E

Report from a CQC angle,, but we'll have either Monitor or TDA, together with the.

E

Trust, local Healthwatch,, the Commissioners, etcetera, present,.

E

And that,, it is at that meeting that an action plan has to be hammered out.

E

With clear responsibilities for who is going to take things forward and within.

E

What timescales, so that then CQC can know at what point we'll go back in.

E

Because we'll know that the actions should have been taken within six.

E

Months,, so that's how I envisage it working and I've certainly talked to.

E

Monitor, TDA and commissioners about that, and they seem to think that's a reasonable way. Forward.

A

≫≫≫ Can I ask one question, as a clinician,. If you make a mistake, would.

A

Your advice be to other clinicians to go to the patient immediately and say: I've made a mistake?.

E

≫≫≫ Yes it would.

E

And I, think that that is something that we were not brought up to do as clinicians.

E

We have been far too tardy in doing that in the past,, but I think the mood is changing.

E

As always the mood perhaps doesn't change as quickly as one would like it to.

E

Do, but I think there is now a far greater emphasis that that is the right thing to.

E

Do, now we need to make sure people actually do it.

A

≫≫≫ It's admitting a mistake and saying: you're: sorry isn't it, two things,.

A

Not one --, it's both things.

A

I just wondered. If clinicians did that as a matter of course,, it would solve so many.

A

Issues early on wouldn't it,, because that's what people want to know,.

A

That, actually, you made a mistake, you're sorry, and they also want to know that it.

A

Won't happen again to somebody else. Is the third thing.

A

I just wonder whether we couldn't with the Royal Colleges maybe,, put out some.

A

Very clear guidelines to clinicians.

E

≫≫≫ Yes I think particularly with the general Medical Council for example,.

E

I think that's where they have a role.

E

I. Think again, we have to look at why it may be that clinicians wouldn't do that,.

E

And it may be again because they are fearful of what that might mean to either.

E

Their reputation or to whether they can get struck off or whatever,, and so it is.

E

Important to look at the culture in which they are working, and again, it depends.

E

What the nature of the mistake is,, and if this was reckless,, then that's quite a.

E

Different matter than from just making a mistake.

F

≫≫≫ Just a couple of quick points,. The first one is not the high risk,, not the low.

F

Risk but the belly of the distribution curve is where I think just to say. We shouldn't.

F

Really take our eye off the ball in that area,, where the hospitals themselves.

F

Look okay but there's something in each of them. That's an issue and that may not.

F

Easily come to light because they're not yet on the high risk list,, so I guess.

F

It's just a plea to keep track of those things where it's just one or two little.

F

Blips of signal, not a lot of signals, but actually they could be fairly important to show.

F

Just, the other one,, clearly the question of who does what, after the regulators.

F

Have found problems, in a sense, we have to work with other regulatory.

F

Bodies as you describe,, but there is a layer between the board and the.

F

Regulators as to who might act, and one of that layer could include, for example,.

F

The academic health science networks, who are collectives or supposed to be.

F

Collectives, I'm, just thinking of David Fisher's, presentation,, David and Robert,.

F

Some of them, some HSNs are more developed than others,. It's not in our.

F

Powers yet, but maybe there's some collective power we could think of or in.

F

Future, that might not put a sanction on, but encourage a network to help one.

F

Ailing Trust,, it's just a thought.

E

≫≫≫ Briefly, in terms of the middle group I, absolutely agree,. I can't tell you.

E

How many different people over the months since Robert's report came out.

E

Have said to me, you know: there's a little bit of Mid Staffs here, in my.

E

Organisation, I'm sure others have heard the same.

E

And so no, we shouldn't take our eye off the ball there,. Hopefully a lot of them will.

E

Be putting that right spontaneously before we even get to them.

E

In terms of AHSNs and others, again the support,. There is a mood change in.

E

The wake of Keogh, where there's a recognition that some of these Trusts.

E

Need external support, now that external support might come from an academic.

E

Health science network or further afield, mentoring or buddying arrangements,.

E

It may come from leadership academies, whatever,, but some of them are going to.

E

Struggle, but we need those Health Services,, because they are in far flung.

E

Parts of the country, they can't do without those and I think that's not.

E

Necessarily our responsibility,, but we can, by having made a good diagnosis.

E

On the hospital,, I think what treatment the hospital needs in terms of getting.

E

Better should be more clear-cut,, and so, if it's leadership support, they can get.

E

That leadership support from wherever.

C

≫≫≫ A couple of points, one is on what happens after the inspections, and.

C

There's a kind of perception out there in that it could lead to you get put on.

C

Special measures and ultimately you could be put into administration or.

C

Closed, and even some people feeling there's a kind of vested political agenda.

C

There,, which I have no idea, but I, guess whether we need a clearer message.

C

Around improvement in support,, because -- and again it's not just CQC.

C

But if the outcome that we did a diagnosis and then the support that was.

C

Offered wasn't appropriate or enough, and then the service or hospital or.

C

Whatever eventually got shut down, or, you know, I. Think from the public's point.

C

Of view, that may not be a good outcome, shall we say.

C

Maybe, sometimes that is the right outcome,, but at the moment it feels the.

C

Emphasis is on failure and shutting down rather than improving and supporting.

C

And, of course, I know the first 14, where there probably were problems so that.

C

May be part of the reason for that,, so it's just the,. If you like messages for the.

C

Want of a better word. The other thing on mental health, side, very quickly, I think we really do have to.

C

Say mental health and learning disability every time,, because in some ways it.

C

Seems a subset of mental health, but I don't think it is, I think it should be.

C

Mental health and learning disability, and I'm pleased to have the.

C

Reassurances that we're cracking on with it,, but also to say that the majority.

C

Of mental health and learning disability services are not in hospital,.

C

They're actually in the community,. So when we're developing our surveillance.

C

And inspection model we're going to have to develop it so that it covers where.

C

The majority of people are as well as the hospitals.

E

≫≫≫ Very happy always to refer to mental health and learning, disability and.

E

Correct me, when I, don't please.

E

I think the point about the support for struggling Trusts, I think one of the.

E

Advantages of having looked at a whole group of struggling Trusts together.

E

Through the Keogh process, is that that recognition is there, almost as if they.

E

Had been dealt with one by one, maybe that wouldn't have been recognised,.

E

They would have been thought of as isolated cases,. The fact that the decision.

E

Was made that 11 needed to go into special measures? I think has woken.

E

People up to the fact that this needs support not just putting people into failure, regimes.

L

≫≫≫ Can I just clarify what do we want our role to be, when you have the.

L

Meeting on Friday with TDA and Monitor,, what are you going to be arguing for that? The CQC should do and if we have new leadership teams going.

L

In as a result of special measures, does Mike have a role in appointing.

L

Those people, can you clarify what you think we ought to be arguing for?.

B

≫≫≫ This might be a three-way answer,, so let's,. This will be a challenge to how.

B

Joined up, we are won't it.

B

So. The way the Care bill anticipates this,. The way that we've been thinking and.

B

Preparing for this in the conversations, is that our job in relation to hospitals is.

B

To assess the quality and safety of services, that, in a sense, is the way one.

B

That Mike is talking. About.

B

It is not our job as conceived by the Department that we then go in and.

B

Intervene in anyway, that can be construed as being improvements.

B

Because, when we go in again to check that improvement has taken place,.

B

We don't stray into that. Territory, I think the phrase that is often used of.

B

Marking our own homework.

B

So on health, care,, acute hospitals,, there's quite a separation between the.

B

Assessment of whether quality and safety is evident in the services and.

B

How we assess and judge that from any action, that's required.

B

And, that's why I refer to the Care bill,, because, although it is called the failure.

B

Regime in the way that people are using it, I think Mike is right to pull out this,.

B

That the intervention is really about improvement,. The whole purpose of this.

B

Is so services don't fail, I think this is your point earlier Robert,, certainly the.

B

Surveillance methodology that we've been working on is so it doesn't fail,.

B

We can intervene at an early stage, so it doesn't fail.

B

So there is that quite strong distinction.

B

You're doing the meeting on Friday, I think,, so I'll, let Paul say this, what the.

B

Ambition of the meeting, is. I think there is a legitimate issue with how -- and David often makes this point.

B

It's in our strategy of we're separate from the system,. Our judgments have.

B

Got to be independent of the system and this is,, this positioning on the side.

B

Of patients,, so our default has not been gosh. It's tough in this hospital, or this.

B

Clinical commissioning group is struggling for money,, it's got to be, are.

B

People who use this service well served in terms of quality and safety?.

B

I, don't think we can be devoid of the context within which that is operating,.

B

We can't be unthinking of unknowing about that, but our judgment is really.

B

About the impact of quality and safety.

B

So I think that's what we are in effect negotiating,. So our memorandums of.

B

Understanding, the way we'll react,, how do we share information within that.

B

Context on surveillance, once -- Mike's point about once: we've done.

B

An assessment of a hospital we come together on these quality summits,.

B

What's the nature of the conversation? Well, the nature of the conversation is we have found this,? This needs to be put.

B

Right,, who is going to take responsibility for putting this right?.

B

We step back on, we have found this, another step forward and say who is.

B

Going to put this right?

B

We then withdraw from that,, not in a callous way,, but in a way that then.

B

Allows that improvement activity to actually take place.

B

We'll set the timeframe over which that check takes, the judgment there will be.

B

About the degree of risks that people are presented, with.

B

And, we'll have to go back in again to check,, so I think these questions about.

B

When will we go in, within that 12 month period? Etcetera, are really.

B

Calibrated depending on what the issues were in each of the 14 hospitals and the.

B

16 that we're going to go in, but Paul, do you want to add?.

G

≫≫≫ Only to say that the purpose of meetings like the ones on Friday is we.

G

All agree to the high level principle, the three-stage process. You have laid out.

G

And will be in the Care bill,. But the assumption is that the devil's in the.

G

Detail, so we're trying to work through what does it really mean at each of.

G

Those stages, so we don't get caught out.

G

So far, there's an awful lot of goodwill to do. This,. We have used the phrase with.

G

The commissioners, it's overlapping, but legitimately different interests, too, and.

G

We continue to hold the line as David says,. We are there to expose and we.

G

Cannot get into the action plan ourselves and we'll continue to hold that.

G

As an important principle.

E

≫≫≫ Just to say we clearly,, the three of us are aligned on this, which is good.

E

News,, and the only thing I would add, is that in the precision of the diagnosis.

E

We'll help others to know what it is. That is the support, that's required and if I can.

E

Pursue this analogy a little bit: further.

E

I'm a physician by background, if I make a very good diagnosis, effectively the.

E

Surgeon, then knows what to do, but I then follow up and make sure that the.

E

Surgeon has made somebody better.

D

≫≫≫ One other point of clarification on Camilla's point, I. Think as part of the.

D

Keogh review, in one hospital at least, the review panel closed an operating theatre.

D

Is that part of the CQC's powers,, when you undertake an inspection, to be able.

D

To do that,, or was this something specific to the Keogh reviews?.

E

≫≫≫ Actually, my understanding is that what the Keogh reviews could do was.

E

Escalate it to CQC,, but in practice that's not really often needed.

E

If you've got a good panel and a good panel chair who goes and then talks to.

E

The Chief Executive and says your operating theatre is unsafe,. Are you.

E

Prepared to take the risk on operating on anybody in that theatre in the next 24.

E

Hours,, actually, the Chief Executive, who doesn't close it themselves, is taking a big risk.

E

So I think that is what in fact happened and my understanding at that one Trust.

E

So my experience with the cancer peer review programme over the last decade.

E

Is that we have quite frequently identified immediate risks, and we have.

E

Always escalated them to the Chief Executive there and then,, and to the.

E

Best of my knowledge, those immediate risks have then been acted on right, away.

B

≫≫≫ I think this speaks to Michael and Camilla's point,. One of the changes.

B

The Care bill is introduced is our ability to take enforcement action is partly.

B

Constrained by the fact that we've got to issue a warning notice in a number of.

B

Situations before we can take enforcement action.

B

The Care bill is removing the need for a warning notice to be issued before.

B

Enforcement action can be taken,, so that makes -- the point that Robert was.

B

Making,, it closes the gap within which we can delay taking action, so we can.

B

Take action immediately,, so there are some enforcement actions that we don't.

B

Take, one is spot fines in effect where we've had that ability. Now, since CQC.

B

Was created but I think no more than four of these have been taken during.

B

That time, and they've all been taken in adult social care I think rather than.

B

Anywhere else, but I think Michael to your point about closing operating.

B

Theatres, CQC has taken action to actually take, reduce the number of.

B

People in A and E by a change in the registration conditions. Basically, and we.

B

Can do that within our powers,, so when I presented earlier and I talked about.

B

Strengthening registration, there is some of the legal powers that we've got, which.

B

We can use to enforce and again historically, CQC have not really used.

B

Those powers in that way,, so there's work going on within the organisation, so.

B

We can actually develop the use of the powers we've got on registration as well.

B

As the Care bill giving us a more immediate way to intervene, if we've got.

B

Immediate concerns about risk.

A

≫≫≫ Mike thanks very much for that, Paul surveillance, model?.

G

≫≫≫ If I introduce agenda item 8 then.

G

As noted elsewhere in the board meeting, the, we're furthest advanced.

G

On the acute surveillance,, there's no doubt about that.

G

The next seminal moment, as far as acute surveillance goes,, will be the.

G

September list; your point earlier Jennifer,. How are we going to get.

G

Around the problem that there will be a lot in the middle of the curve?.

G

One of the ways we can do that beyond just the on-going running programme of.

G

Inspection is by publishing this list with all our surveillance indicators and.

G

Making it very transparent to providers, commissioners and others in.

G

The system where we have identified concerns, identified smoke, alarms and.

G

In the new architectural quality surveillance groups, I would expect these.

G

Lists to start being used as a questioning device; are you doing such-and-such on.

G

An outlyer and that's, of course, in addition to the fact that we haven't,.

G

Our resource model won't imply that inspectors are always on inspections.

G

And not able to do anything else other than what they are currently looking. At,.

G

They will have capacity to also checking up as to whether these things have been.

G

Followed up, but I introduce that as a key example of how the surveillance can be.

G

Used more broadly than just ourselves.

G

The place, I draw your attention to on. The document is table 1 on page 3,, because.

G

That lays out where we think we can get to, mirroring the acute process of when.

G

We'll have a date for the proposed first version of the indicators and then, when.

G

We'll be able to publish a full list, two points on that table.

G

One is the next sector, if you like,, where we're aiming for is the mental health.

G

Sector, closely followed by acute hospitals and learning disabilities.

G

The reason for that is very much a risk based judgment,. It will take us longer,.

G

We are in the --, particularly mental health. We've conducted a literature.

G

Review and we're now going through the exercise, you'd expect to look at all the.

G

Different indicators on the same model that we use for acute hospitals,, tier 1,.

G

Tier 2 and tier 3,, with tier 1 driving our direct surveillance, to put it that way.

G

I also draw your attention to the fact there are TBCs on that table and that.

G

Simply reflects that this is a very large programme and it wouldn't be.

G

Appropriate to say, we've got it all under control,. We know exactly when we'll do.

G

Everything by,: we are trying to bite it off in chunks and use a risk based approach.

A

≫≫≫ Is everyone happy with that schedule?

A

F

≫≫≫ Just on my worry list,, which is the out of hours primary medical services.

F

And not to have a date for that I think might be a bit worrying at this point.

F

But I don't know if you have anything more to say.

F

≫≫≫ No I think that's right,. That will be the next one. We have to go to,.

G

We just need to make sure we have the resource to do these things,.

G

But absolutely it's a worry.

A

≫≫≫ Winterbourne View is also you.

G

≫≫≫ I think it's a run of papers, I'm introducing so apologies. If you get bored with my voice!.

G

So, this paper builds on a previous board paper and seeks to update the board on.

G

The four different reviews,, both internal and external,, which have followed the.

G

Abuses that were exposed at Winterbourne, View hospital,, they are.

G

The internal management review that we conducted, our overall look at learning.

G

Disability services,, the Safeguarding Adults Review, case review and the.

G

Department of Health transforming care response to Winterbourne View.

G

I think the summary here is that there have been a lot of actions that we have.

G

Committed to undertake,, many of which are rolling out or have been rolled, out,.

G

Some of which haven't- and the next step, therefore, is the simplest one, but we'll.

G

Continue to do what we've said we'll do,, but there is a step change that is.

G

Needed,, which is that we need to layout what our approach to regulating learning.

G

Disabilities, hospitals, like Winterbourne View, really is, and that's in the same way.

G

We've gone to some distance to doing so for the June 17th consultation document.

G

On the acute Trusts,, we need to do that for this group of providers, just as frankly,.

G

We need to do for all the other sectors and that's what will really change and.

G

Give us sufficient confidence that we're regulating in appropriate ways and then.

G

Of course, roll out the programme of inspections again analogously to the.

G

Way that Mike described for the acute sector.

G

A couple of points to bring out within that then,: firstly, the --: what action we're.

G

Taking where there are not registered managers, or they haven't been in place.

G

For a significant period of time,, which is paragraph 2.25 and 2.26, and to echo.

G

David's point,, where we do think we should use more fixed penalty, notices,.

G

We're getting tougher on our enforcement,, it's just not appropriate, not.

G

To have a registered manager,, it's a legal requirement.

G

So for the bands 2 to 5 in that table. We're now taking enforcement action,, including FPNs.

G

And, if necessary, placing restrictions on registration, requirements.

G

The other part is that we've already committed to changing the registration.

G

Requirements for new providers of learning disability services and that.

G

Started from this month,, it is for new providers only,, but it's explicitly there.

G

To ensure that there is a clearer understanding on behalf of directors of.

G

The, or leaders of those providers as to what their legal duties are and how.

G

They're going to fulfill them.

F

≫≫≫ Just a point on page 5 at the top under 2.8, that some of the lessons.

F

About the oversight and supervision was to culminate in a public report to the.

F

Board but hasn't yet been implemented,. Could you say a little more about that.

F

And is it going to come as envisaged?.

G

≫≫≫ Let me follow up on that,, but I would absolutely --. If we made the commitment it should come to the board, yes.

G

I'll follow up and find out.

I

≫≫≫ So I'm pleased that we're taking the action where there aren't registered.

I

Managers but I just wondered what the response of these organisations.

I

Has been, if anything?.

G

≫≫≫ I don't have details on the individual ones, no,. If I'm honest Steve,.

G

I wouldn't feel confident to say, I think you can imagine the range that we.

G

Might expect, but no, I, don't feel confident to say about individuals.

I

≫≫≫ I think the motive for the action is to try and get registered managers in there not to actually close them. Down.

A

≫≫≫ You can come back to us at the next board. Meeting on that, could you?

A

C

≫≫≫ Thanks for the update,, it seems a lot of the issues will be covered and.

C

Addressed in the new approach, which is good, but what I'm worried about is the.

C

Next year or so,, because what we have is a very vulnerable group of people and.

C

We have got cuts to services that are starting to bite and also the changes,.

C

So I'm thinking over the next year that I'd really like to know that we are keeping a.

C

Firm focus on this group of people,: yes, we're going to do things differently, but.

C

You've got a year at least, a challenging time and one thing,, for example. This link.

C

Between Mental Health, Act, Commissioners and Inspectors still.

C

Doesn't seem to be working that well,, at least across the board and I, think it.

C

Could be a fairly pragmatic thing that we make sure that they do actually speak to.

C

Each other, they've got their email addresses or something. But, just to sort.

C

Of make sure, in this kind of crucial time that we don't take our eye off the ball.

C

There, because they are so vulnerable.

E

≫≫≫ Just to say Kay, that the link between Mental Health Act work and the.

E

Rest of mental health and learning disabilities is very definitely on our radar.

E

And how we can try and make that work better together,. Certainly that's.

E

Something that's been brought to my attention very quickly.

A

≫≫≫ Just on that Mike,. How soon will you be able to make an appointment to.

A

Someone to lead our mental health and learning difficulty efforts?.

E

≫≫≫ I haven't got a date on that yet, we're still trying to work out what the.

E

Exact structure should be,, but what we have got is a lot of people who are very.

E

Willing to help us get going and we've got good people within the organisation.

E

And outside who are assisting us on that and I think that will make it clearer.

E

In what way we need to go in terms of having somebody leading on that.

C

≫≫≫ Also, the interim as well.

C

I know there is the changes,, but it is the interim.

C

Somebody I know recently,, their son died in an assessment in treatment unit.

C

For people with learning disabilities.

E

≫≫≫ I completely take that and I think we need to take that away and look at.

E

What the programme is that we have ongoing through the Regional directors.

E

And come back with: what are we planning with this year,.

E

I made a clear note on that.

A

≫≫≫ We'll come back to that at every meeting. From now on, Mike you can be assured of that.

A

≫≫≫ Thank, you very much.

I

≫≫≫ Steve? >>> So on case point and not intended to be an answer because I'm not in a.

I

Position to give you an answer.

I

First of all I think we as a board have to appreciate the enormous pressure on.

I

Mike and David and their teams to deliver this in very, very quick time and.

I

Some of that's a political agenda and I think we've just got to make sure that.

I

We as a board make sure it's delivered appropriately,, as well as as quickly as possible.

I

But, the second thing is I. Think I picked this up yesterday when I was on an.

I

Inspection;: it's a mistake to think that our inspection teams at the moment.

I

Don't realise what's going on and they describe their inspection when we went.

I

To St. Mary's as the old system plus,, and they are trying to change it.

I

They are trying to introduce new methods within the existing,. They have to.

I

Say we're still going to assess whether you are compliant or non-compliant, but.

I

We'll be looking at this and we have an expert with us, etcetera, etcetera.,.

I

So I think there is movement and one of the advantages of the extensive.

I

Consultation process we're going through, is that people are picking this.

I

Up, they're, anticipating the changes and welcoming them and I think they're.

I

Being incorporated as we go, so I think the picture isn't from black to white,.

I

There's a whole range to go. Through.

F

≫≫≫ Just, an addendum to that, I presume. The same is also true for the.

F

Surveillance system that there is an existing surveillance system on which.

F

You will pull on your team developing,, so the TBC in some of those areas.

F

Back on the previous paper on table 1,, there is some ongoing surveillance,.

F

It's just not the developed surveillance that you want to see.

G

≫≫≫ That's right,, for example, the way that we get safeguarding alerts as one of them.

G

There is surveillance,, but I agree with Kay that we absolutely need something.

G

In the interim, and we will and Steve is right about the way that things are.

G

Progressing,, but we are so sufficiently far from where we need to be on this.

G

Sector that I'm equally mindful we mustn't, give ourselves false confidence.

G

That using better what we have is going to be enough.

G

We need to do it as a stopgap, but we need to transform the way we regulate.

G

This sector in particular.

A

≫≫≫ Thank you Paul, corporate performance?.

A

N

≫≫≫ That's all right, I've got some questions and comments on this one. If.

N

That's all right. The first point I wanted to make was that although there's been some.

N

Improvement in the number of inspections, where the remedial action.

N

Has not been taken within less than a year,; in other words, they are still.

N

Non-Compliant after more than a year,, been declared non-complaint,, although.

N

The number has gone down in most cases, not all,, but most cases,. It is still.

N

Worryingly, high, and I still am anxious that we are tolerating organisations that.

N

Have been declared to be non-complaint and leaving them for a.

N

Long time before, subsequent enforcement action is taken.

N

Something's getting better, but still some very long delays in putting things right.

N

The second point I wanted to mention was I think that the inclusion of the.

N

Feedback from organisations that have been inspected is actually really really.

N

Helpful,, this is the first time I've, certainly seen this, I, don't know if it's been done. Before.

N

And the knowledge that was clear a few years ago that we were sending in.

N

Inspectors to inspect organisations who didn't know very much about what was.

N

Going on in that sector is still there. In a worryingly high proportion of cases,.

N

In some cases, up to 20 percent of those inspections are conducted by people.

N

Who give the impression of not being clear about what it is that they're.

N

Inspecting and I hope that that can be addressed, because I think that is a.

N

Longstanding criticism,, which really we ought to have eliminated by now.

N

My third question is about the complaints, building on the discussion.

N

We've had this morning, I think it's probably good news that we are getting.

N

More complaints, because we had a significantly low level of complaints.

N

Historically, so I think it's good that people feel able and know how and are.

N

Able to make complaints, and I don't particularly now want to go into a long.

N

Detailed explanation of exactly who made what complaints about what,.

N

But what I would like,, either now or at some point in the future,, is to be clear.

N

How these complaints are dealt with?

N

60 of the complaints were about members of staff and I'd like to be.

N

Reassured that those are being considered at an appropriate level in the.

N

Organisation, that action is -- if there are patterns about where those complaints.

N

Are that is being picked, up, action is being taken and that, if there are lessons.

N

That we need to learn or need to be reported to the board that that process is.

N

Going to take place,, thank you. David.

A

≫≫≫ Paul: do you want to respond to that?.

G

≫≫≫ I think we'll come back to you on the final points on complaints and.

G

Whether that 39 percent of the total number that's about the conduct of staff.

G

Overall on the report,, the point to get across,, particularly on the activity side of.

G

The programme, we are broadly on track and that includes, that's on track against.

G

A 49 week, programme, so builds in three weeks at the end as well.

G

So I think there is a level of assurance that we can give that our activity.

G

Programme is doing well.

G

I think it's right and it's good that we have the quality measures in terms of.

G

People telling us what they thought of our inspection,. We do need to follow up.

G

On the point you raise that not all our inspections are seen as credible,. That's a.

G

Fundamental part of generalist to specialist switch, which we need to roll out.

G

The piece that I know we've discussed on the executive team and will continue.

G

To get better on, is the way that we assure ourselves of the quality of our.

G

Regulation by sector,, not just that we have been in and seen stuff.

G

And, that is part of our transformation, programme.

G

Just, a couple of other areas, I think we should flag, the transformation.

G

Programme that Hilary can comment. On, is overall rated amber red with four.

G

Particular high risks, and although that does reflect the nature of the.

G

Programme,, that's it's very large,. It's taking part -- it's high profile and at an.

G

Early stage,, nonetheless, we want to highlight that we do need to mitigate a.

G

Whole series of important risks there.

G

We have deteriorating performance on the compliance reports within 25 days,.

G

Which is something that we're therefore clamping down on,, but to highlight that,.

G

Those would be the areas I would highlight as remaining concerns,.

G

But it's in an overall good context.

B

≫≫≫ Just on this point about complaints, we previously had, I'm reaching for the.

B

Date now and I can't quite put my hand on it, a report which did analyse.

B

The nature of complaints and I think our commitment was that there should be a regular report to the board, which did exactly that point. John.

B

I think what this report is flagging up is that, following the publication of the.

B

Grant Thornton report,. We had a spike in the number of complaints coming in,.

B

We've had a spike of FOI requests and a spike of subject; access requests that.

B

Have been considerable, and I think that's the increase that is showing.

B

Through the figures that you've got here,, but the basic point of doing that analysis.

B

Of what do these tell us, rather than how many we had, and what are they about? Is.

B

Something we'll pursue, so we'll do that.

B

Can I just say one more thing?, I'm, not sure at what point we'll get to specialist on our inspections, before.

B

April '14, if I'm being brutely, honest, so I know these questions will keep coming,.

B

But we're on a trajectory to begin to change the structure and the original.

B

Timetables we've been setting out do not see us complete that migration to.

B

Completely revised structure until the autumn of 2014,, now one of the.

B

Questions I have been asking is given: we've made good progress on bringing.

B

In Mike and Andrea and the other appointment, is there a sense in trying.

B

To bring forward some of those dates, or the change management, theory,.

B

Make up your mind then do it and do it quickly.

B

The challenge we've got is we've got 44,000 inspections to deliver this year to.

B

A standard, to a quality that you will ask us about and with the enforcement.

B

Action that needs to be in place, which is the other challenge and therefore what I.

B

Feel we're constantly balancing is the speed at which we make the migration.

B

To the future state, without prejudicing the invention of the new methodologies.

B

And tools that we need to use and delivering our current responsibilities,.

B

So the original timetable we've been looking at sees a transition to the fully.

B

Changed structure in October '14,, but not moving the bulk of people into new.

B

Jobs until beginning in April, '14,, so I don't think those absolute numbers of.

B

20 percent you quoted John, on our current plans unless we bring them.

B

Forward will actually change substantially till that point in time.

B

Therein after it will change,, but within that I expect that 20 percent to move as.

B

People specialise,, where people opt to do health, inspections, care inspections,.

B

Or effectively a primary medical service inspections, as we move towards April,.

B

And that transition is pretty much taking place, now.

B

But, the distribution of our staff is uneven quite frankly, and we do intend,.

B

It's just being finalised after the gremlins have been chased out of it, a skills.

B

Audit, which, for the first time,, will give us a full audit of the skills of our staff,.

B

Sad to say, we don't have that, I honestly cannot tell you, bar when I go and speak.

B

To inspectors, put your hand in the air if you're a nurse, put your hand in the air, if.

B

You're, a social worker,, put your hand in the air if you're something else and I.

B

Think that's broadly working on, 60 to 70% are from a care or health.

B

Background and there's 30% or so who are from a much more generic background.

B

Now, some of that might be non-clinical management in the NHS,. It could be a.

B

Background of performance management in a local government.

B

Setting or it could be they're a police officer, could be teachers,.

B

So we actually need to sort all of that. Out.

B

The fact is: we've got a duty to every single one of those members of staff, because they're our employees,. They were recruited in good faith on the.

B

Understanding we have a generic model of inspection, so part of what we need to.

B

Do is make that transition,. That's why the academy is important.

B

I don't mean to go on about that, but they are the judgments and we're constantly.

B

Reviewing should we drag some of this forward in relation to how we should.

B

Move forward, at the minute: it's just staying where it is until we've got more,.

B

Your question to Mike about when will the head of mental health come in,.

B

I think we'll put the advert out after the holiday period, no point in doing it. Now,.

B

That's September,. That means body not in until December,, so I think we're in,.

B

There is a rhythm to use the phrase that Paul used earlier of making a decision.

B

About what people you need and then recruiting them, and that rhythm is.

B

Probably about a five or six month from beginning of the decision to the body or.

B

The person appearing and beginning to come, in,, which really pushes us into,.

B

I can't see some of these changes taking place until '14.

N

≫≫≫ David, if I may,, one of the factors, may be, it's difficult to know without.

N

Understanding the data more effectively,, but one of the issues may be that as you.

N

Slice and dice your workforce to make it more specialised. You take account of.

N

The geographical distribution of that workforce across the whole country that.

N

Actually, you have to have more than the theoretical number of people that.

N

You need, otherwise, because you don't have them in the right places to be able.

N

To do the right inspections at the right time, now that may well have.

N

Implications for the recruitment of your bank inspectors, which has to be.

N

Sufficiently early in the year to give you that flexibility later in the year,, so I think.

N

That's the point that you might want to consider in terms of recruitment and.

N

Flow through of the raw resource into the allocation that you're making.

B

≫≫≫ Quite so. So on Monday of this week, Paul brought some what I thought was outstanding.

B

Work of profiling and modeling the number of inspections we need and.

B

The number of staff we need to do that, suffice to say that was done by an.

B

Analyst, not a strategic HR person that then converts that into what is the future.

B

Workforce in 13/14,, 14/15, 15/16 and when we get to our steady state. What.

B

The steady state numbers are.

B

The only way to do this is tell it straight.

B

We, don't have a strategic, HR capacity,. We need to recruit that strategic HR.

B

Capacity, then we need to look at what is the skill mix and numbers we need, as.

B

We go through; I would argue the next five years, as we build all these models.

B

Up so we can actually answer these questions.

B

What we've got is some fantastic work, we've done on hospitals, but we need.

B

To do that, modeling for adult social care and primary medical services before.

B

We can say this is the optimum number of people we need and if we're going to.

B

Have a further conversation with the Department of Health about resources.

B

We need to do the job, the capacity we need to do the job, as distinct from.

B

The capability we need to do the job,, then we need to have those numbers by.

B

October,, so this is a bit of a burning platform,, because the last conversation.

B

We're a going to have with the Department before we go into the.

B

Election and therefore in this government's term, is this autumn,.

B

Whatever the 15/16 spending review says,, that will be another government.

B

That takes that forward.

B

And. Therefore, our burning platform,, so I've asked Paul to do as much work as.

B

We can to repeat what we've done on the NHS where,, as we've heard during.

B

Today, we've got more data on the NHS than we have in social care and primary.

B

Medical services, because we need to do that strategic HR work about capacity and capability.

B

Question,, do we have enough money to employ the people we need to do the job,? Have we got the right skill mix? We need to do the job?.

B

On inspection teams, what will our employed workforce be as distinct from.

B

What money do we need to buy the skill from people that are doctors and.

B

Nurses in hospitals that we need to be part of the teams, etcetera.

B

And, so that's summer's job for Paul.

L

≫≫≫ Clearly: we need to make sure we've got the resources to do the job.

L

And sounds as if the predecessor organisation didn't necessarily make that.

L

Point sufficiently. But also. Is it our role as a board to make sure we spend that money effectively?.

L

Do we have a finance committee of the board and, if not, can we have some.

L

Sort of consolidated, P and L, I don't know about everybody else, but I can't.

L

Actually read from these two finance documents: they do not assure me that,.

L

I can't see our cashflow and I can't see whether we are in budget,. You know what I mean, I don't know in what form it will be most helpful to have that.

L

Information or whether we have a finance committee which is responsible for looking at that,, but it's surely part of our role as a board, isn't it?.

A

≫≫≫ We have an audit committee of the board, John. Do you want to explain what you do on that?.

N

≫≫≫ How much time have you. Got? We have a combined audit and risk committee and the audit committee.

N

Deals with the sorts of issues that we're talking about,, we don't have a cashflow.

N

Because we're a public body so we're bank-rolled by the Treasury basically,.

N

But the issues about efficiency and effectiveness are very much in our.

N

Domain and that's something I feel very strongly about, and I'm happy to talk to you outside the meeting. We also have obligations to give the board assurance about whether the risk,.

N

Both corporate and regulatory risk is being properly managed,. We don't do it,.

N

That's the job of the executive, and the risk, the judgment about what are high.

N

And low risks is for the board, not for us,, but what we do is then say whether.

N

Those risks are being analysed,, assessed,, mitigated properly and give.

N

The board assurance,, because that's quite a detailed process of going through.

N

Mitigation plans, and so on. So, that very quickly is what we do, but I'm happy to pursue it. Outside.

L

≫≫≫ Sorry one point, I, don't know if everybody else knows this, is there a.

L

Threshold of expenditure that ever needs to come to the committee or the board?.

L

Can David spend an unlimited amount of money, or is there a point at which...

N

≫≫≫ We, don't do executive actions,, we don't authorise particular levels of.

N

Spending,, that's for the executive and for the scheme of delegation,.

N

Which David is responsible, for.

N

So? We don't do that side of it.

N

You have to direct that question to them.

B

≫≫≫ Having been so directed,. This is a performance report.

B

It's, not a finance report,. You do get a finance report Camilla, which will go.

B

Into detail and I would hope that would satisfy the questions. You've got and the.

B

New director of corporate services will take responsibility for that, but Francesca.

B

Is the head of finance, she's, a qualified accountant and I think she'll present the.

B

Information appropriately,: this is a new form of presentation,. This is John's.

B

Reflection and we'll work at getting the finance report right.

B

You do have a responsibility to challenge on value for money and.

B

Effective spend that's absolutely right,, as accounting officer I have a personal.

B

Responsibility back to Parliament for that as well,. So there's a kind of double lock.

B

On this one,, which feels uncomfortable at times.,.

B

I think our finances are relatively straightforward to be honest.

B

I've been responsible for budgets as a director of social services which have.

B

Just been a nightmare to manage; unlimited demand against fixed amount.

B

Of money is really challenging,, we're pretty steady on this.

B

And there's a later report at item 11, sorry, there's a later report, which I'm.

B

Asking your permission,, because I've got a delegated limit up to 500,000 therein.

B

After above 500,000, I need to do that in consultation with the board. So there's a.

B

Report later for the renewal of the NIT contract, which is total value over the.

B

Period, 1.4 million, so I can't make that decision by myself. So there's a report to.

B

Ask you to make that.

A

≫≫≫ So, the answer is: half a million quid to Camilla's last,, anything more.

A

Than half a million has to come, here.

B

≫≫≫ I need to check,. I normally have the check on the scheme of delegations, but there's a Treasury driven, cabinet office, regulated scheme of delegations.

B

For all arm's length, bodies and people like me,, it's pretty well laid out.

H

≫≫≫ Thanks, very much,, so I think this report,. If my memory serves me right.

H

This report looks very different to reports we've had before so I kind of want to.

H

Start by saying thank you,, it feels like it's got a whole lot, more, really useful.

H

Information in it, which we might have wanted to have for a long time,.

H

So, thanks to you and the team Paul.

H

And so one reflection, you asked us to reflect on presentation and what was.

H

Really interesting for me, was, and in a way this is an acid test of these kind of.

H

Reports,, what was really interesting was what you said by way of introduction.

H

Paul about which issues you thought were worth remarking, on, and that's.

H

What I think we're missing in this report,? So we've got a long textual introduction.

H

Which repeats what's in the slides and actually what we need is,, and these are.

H

The five things that we think as the executive are issues which need to be.

H

Addressed and you need to assure yourself that we have addressed, in the.

H

Sense, the very fact that you've surfaced those five and not 20 is indication that.

H

Your heads are in the right place and that, for me, is part of the test and it.

H

Sounds like they are in the right place, because they are the things that pop out.

H

Of this report,, but does include actually perhaps additionally, this question about.

H

Age, non-compliance which you're quite right is dramatically improved, but.

H

Perhaps not yet in the place we want it to be,, so something about direction of.

H

Travel but not yet there.

H

So. That's all good for me, having seen a variety of other presentations of this,.

H

Definitely going in the right, direction.

H

I wanted to have one word about the strategic risks, and this is covered in two.

H

Places, so on page 11 and they be in the strategic risk. Register, I, particularly.

H

Wanted to focus on the one around public confidence,, so there is a.

H

Suggestion that it needed to be reframed not about whether or not our reputation.

H

Would be damaged but how we could rebuild our reputation, actually in the.

H

Table it talks about levels of public confidence is really what this is about,.

H

I think the assumption is, I'm sure it's a correct assumption that levels of public.

H

Confidence has reduced,, our task is to increase them, but what matters is how.

H

High they are and how high they should be, that's the test here, and that makes.

H

Me want to ask a question about: do we know,? What do we know about public.

H

Confidence in the CQC and how are we going to measure this?.

H

Because, it seems to me that you've got some measures in here around the.

H

Consultation responses and impact on what I think are probably more likely to.

H

Be stakeholders of the work we do over the course of the next period. But if.

H

We're concerned about levels of public confidence per se,. We need to do that.

H

Work and now is a very good time to get the benchmark because we suspect I.

H

Think reasonably that it might be as low as it could be, so it will give us a good.

H

Test for how much we can improve it over the next period of time.

G

≫≫≫ Our first challenge is to know who even knows about us,. If I remember.

G

Rightly, it's something like 4 percent, unprompted recognition and possibly.

G

19% prompted, but slightly going up.

G

Absolutely, yes, to get to the baseline and then measure that's what we need to do,.

G

But I think even then we need to just distinguish between people who know.

G

About us and their view versus people who don't know about us and we can.

G

Take a view of whether we're comfortable,, whether it's the best.

G

Possible regulator is one nobody knows about, but does brilliantly or whether we.

G

Need to be known as well,, but the basic point about having a baseline for the.

G

Data is right, thank you.

J

≫≫≫ This may be pedantic, I think what we're talking about is building.

J

Public confidence, I don't think it's there to be lost.

J

I really don't. Maybe amongst a few people, but it's a different task, because building it is.

J

Actually, a different set of social relationships,, not just being good,.

J

It's actually people, knowing what you're, doing, so I think that's a different thing.

J

And I think we've got to build public confidence.

L

≫≫≫ I'm, being even more pedantic; but isn't what's important, is that.

L

We do a good job,, isn't public confidence going to be correlated with whether.

L

We do a good job, I'm, not sure we should be obsessed with,. We want to be.

L

Very careful we don't look obsessed with PR.

L

There's a case for saying we want people to be able to access, your point.

L

About the organogram,, we want people to have a better understanding of how.

L

They can complain, but that's more important to us than public confidence.

L

Because that's going to rise, if we get everything else, right, isn't it?.

H

≫≫≫ You're, absolutely right: we shouldn't be obsessed with what levels of knowledge there are amongst the general population,. Actually, the reality is.

H

The better a job we're doing the less people need to know about us,. That's.

H

Absolutely true,, but there is something potentially damaging, Paul's also right.

H

We didn't have a reputation amongst the public before,, but we probably do now.

H

And the reputation I suspect,, the reputation we have now is not a very.

H

Good one- and that has a really severe impact not on us but on people's.

H

Confidence in their approach to health and social care services so has a much.

H

Wider concern for me,, so I've always said in other regulators,. Actually, our job.

H

Is not to make sure we're a household name,. Our job is to make sure we're not.

H

A household name that means we're doing a good job,, but in this case the.

H

Fact that our reputation may not be very high is probably damaging and worrying.

H

For consumers and users of health and social care and I think it's important. We.

H

Monitor how the good job we're doing,, which I hope we will be going forward,.

H

Contributes to a greater level of confidence in the way that people.

H

Approach services,, so it's a wider public interest test in a way, rather than a.

H

Measure of our success for me.

L

≫≫≫ Sorry you're, going to hate me, I'm, really worried that when you make --.

L

We're drowning in paperwork already: here. When, you make, it's very important to get this list right,, simply because, as.

L

Soon, as we put public confidence in a box, at some point, poor old Paul is going.

L

To have to be asked to create seminars, leaflets,, you know what I mean, I'm just.

L

Concerned that it's going to -- I totally take your point and I think it's really.

L

Important that we have public confidence but I'm not sure whether we should have it as an output that will lead to a frenzy of activity, I. Don't want to overdo it.

J

≫≫≫ Let me give you an extreme indicator,. Ofsted sets the price of.

J

Houses,, that seems to me, has an impact on the public and that's because.

J

People go there and they trust what it says and they trust so much what it.

J

Says they buy houses near schools to make that so.

J

Now, that may be an extreme, but it means it matters to the public and they.

J

Trust what it says, I'd like people, to trust what we say and to be the go to place.

J

About adult social care and hospitals.

I

≫≫≫ Paul's refinement is having confidence in the judgments that we.

I

Make and that's where we need to have public confidence,, so they actually trust.

I

Our judgements, that they're reliable, robust,, fair and the rest of it,.

I

And that's where we need the public confidence,. Otherwise, what's the role of the regulator?.

D

≫≫≫ I had a slightly different point. I think this is the first time I've seen the.

D

Risk register, so apologies if this has been considered and I'm really making a.

D

Non-Point, but I would have thought the biggest risk the CQC faces and it would.

D

As it happens, affect public confident, is if the surveillance system failed to pick.

D

Up hospitals, where there was a risk to patient safety, I would have thought that.

D

Is the number one risk on the risk register and probably the second risk,.

D

Is that we do an inspection and obviously I'm highly reassured by what.

D

Mike has said about the nature of the inspections,, but that an inspection fails.

D

Also to capture problems in hospital, I would have thought those are by far the.

D

Two most important risks for the risk register, yet they're, actually not.

D

Mentioned,, although you can argue that some of these more generic risks could.

D

Cover them, but I think those -- my own view for what it's worth, is. We should.

D

Specifically have those as risks, because they are the biggest risks and they, as it.

D

Happens, also would risk public confidence because we can't have.

D

Public confidence, unless our surveillance system is effective and our.

D

Inspections are effective. So, that's a point about the risk register.

D

The second point is: I've, never seen a performance report before, so I, don't.

D

Know the extent to which this is an improvement, I'm sure it is an improvement.

D

I have to say, I found it almost unreadable.

D

I didn't really understand what it was trying to do and although I could see.

D

That every section had feedback on the quality of inspections by the.

D

Organisations that have been inspected, I presume that's what the left-hand side.

D

Of these charts, were, non-compliance really puzzled me because what was.

D

The, about what were these organisations not complaint?,.

D

So there was data on proportions of non-compliance, but nothing about what.

D

The compliance was about and were they non-compliant about something.

D

That's very serious,, were they non-compliant to the results of an.

D

Inspection? I just didn't understand: it.

D

So I, don't want to criticise the performance report, as I say: I haven't.

D

Seen the previous versions, but I did find this difficult to understand and difficult to.

D

Know quite how to read it and what to take from it.

D

So as I say,, unfortunately, two negative points in a way,, although I think the risk.

D

Register is very easy to, if colleagues agree, to change and to modify,.

D

The performance report, I think, needs a bit more thought about what it should be. About.

D

For example, there were 96 NHS inspections during quarter one,. What did they find?.

D

There's, nothing in here which says what the results of the inspections were,.

D

So I think there is scope to improve the, to further improve the performance report.

D

≫≫≫ Paul? >>> I'm adopting Robert's point that non-executives should be challenging.

A

≫≫≫ On, the first point about the two risks that you mentioned are the two key.

A

Risks, completely agree, I. Don't think anyone would dispute that and actually, if.

A

We're not right on both those things,. There will be no public confidence in us.

A

At all, and what is the point of us actually, if we don't get those two things, right.

A

So, they should be right at the top of the risk register.

A

They are absolutely critical.

A

And when we publish our surveillance list at the end of September,. If that is not.

A

Right then, that will reflect very heavily on us and equally, when Mike does his.

A

18 inspections, if we miss something in those inspections,, then again that will.

A

Reflect absolutely on us,, so they are absolutely critical.

E

≫≫≫ I absolutely agree, and those are the things that are going to be keeping me awake at night,, missing, things.

E

I think what we need to distinguish between things we've missed, because.

E

They have been covered up,, which may occur and things that were not brought.

E

To our attention,, so we need to be very proactive in asking just to give us.

E

All the information they have, and things that we have missed ourselves,.

E

Although I suspect at some point, we will miss things and I think that is the nature.

E

Of the business and I think we just need to recognise that,, but we need to.

E

Do everything we possibly can to minimise that.

A

≫≫≫ But I think picking up Paul's point about Ofsted, Ofsted have been through.

A

Bumpy times, but their judgments are hugely respected.

A

They may get it wrong on some hospitals, but when Ofsted say a school.

A

Is outstanding people think that is a serious judgment about that school and.

A

Equally, when it's in special measures.

E

≫≫≫ And I'm sure we should aim to get to that same position,, but just to.

E

Re-Emphasise what we've all said before is that hospitals are rather more.

E

Complex organisations than schools and it's Jennifer's point as well that we may.

E

Miss a particular department and something there may be happening and.

E

That is perhaps my greatest concern.

A

≫≫≫ On the performance report, I'm glad you mentioned that Mike, I tend to.

A

Rather, I might glaze over when I look at performance reports and that's a.

A

Bad reflection on myself.

A

Paul: we need to spend a bit more time on this,, maybe Michael. You can help us.

A

With that, to some extent and how we set out this performance report.

A

≫≫≫ I'd be delighted to do that.

F

≫≫≫ So sorry,, it's just what I was droning about on earlier, there's.

F

Something about what's in the performance report, which may necessarily be high level and then there's something which could be.

F

Deeper about what is on the worry list,, because, for example, there's quite a lot.

F

Here about the number of enforcements and enforcement actions and also aged.

F

Non-Compliance,, but in the sense that may be something that one would want.

F

To abstract and have more information on in a separate, worry report.

A

≫≫≫ I will say that the worry list based on Paul's surveillance model is 100.

A

Times better than what we had before.

A

We didn't know what we were worrying about until recently, at least we've got a.

A

Basis for our worries, now, I, think you'd agree with that Anna,. You didn't see it.

A

Before but it's a heck of a lot better, even though it's far from perfect, okay.

C

≫≫≫ I've got a couple of points, one on the performance, report, I think to be.

C

Honest we're partly looking at the legacy issue because we're still delivering.

C

Largely under the old,, well, it's old but current, so I guess it might be better to.

C

Sort of focus on what we want to see as our key performance indicators,.

C

Whatever for the future,, because I don't think --, this has been fiddled with so.

C

Many times, so I think it would be better for us to think ahead about the things.

C

We want to look at based on our new strategy and our new approach.

C

The other thing, I want to say also is a little bit of deja vu in the sense that we.

C

Are delivering a major transformation and delivering business as usual?.

C

Because it was quite similar to that when we started,. Actually it was more.

C

Pressured, so I guess what I wanted to say is that actually we are delivering on.

C

Our commitments that we've made and I think we need to acknowledge that we're.

C

Doing that under quite difficult circumstances and that's quite an.

C

Achievement actually- and it may be that,, you might say we don't know too much.

C

About the quality of our inspections,, we know something about them,.

C

But we have delivered,, we are performing well actually.

C

Plus we're delivering this huge transformation which we must not.

C

Underestimate and hopefully we'll have a conversation around our capacity and.

C

Capability around that.

C

Because as a board. It's. Why didn't you do that yesterday or why aren't you.

C

Going to do until 2014 and you think that's ages, away, and maybe there is.

C

Scope to move forward, but I think you should also push back on us and say.

C

Look, you can do it too. Quickly.

C

It might feel uncomfortable to us, but if it's not possible,, it's more risky to try and.

C

Do it quickly,, too quickly shall I say, than taking our time, so we actually get it.

C

Right, but I appreciate it's a fine balance.

B

≫≫≫ I've been doing this job 12 months last week, I think,. This is the fifth iteration.

B

Of the performance report to this board,, so what is it? Perfection is the enemy of.

B

The good, just to connect Michael's offer or your corralling Michael, to offer and.

B

Kay's point, is I think there is merit -- on the model that Mike's designing. What's a.

B

Performance report we need for that? Because. We are by definition, going to run this out by April next year,, so there.

B

Is a sense; I'd ask the board to consider whether this is good enough to get us.

B

Through the remainder of this calendar year, so what we spend our time and.

B

Effort on is inventing the future, rather than perfecting something we know.

B

We're going to get rid of,, my preference would be to do that, if I could ask you to do that.

B

I think on this issue, Paul I think you're absolutely right and it's a point.

B

Powerfully made and not lost, Michael. You were right about whether we've got.

B

The right priorities in relation to the report, there is an operational risk.

B

Register,, which I think reaches for those exactly those points to be honest,.

B

So again it comes to how do we report this in the appropriate way?.

B

Jennifer, your point is right about whether it's high level and then a more detailed one, which is not a million miles away from what you said.

B

So, the real point, on the confidence point is how it impacts on staff,. So on.

B

The weekend that we did the care homes open day, was the day that we published.

B

Grant Thornton,, so we'd got over 250 inspectors going into care homes on.

B

The Friday after we published the Grant Thornton report.

B

And. They walked right into having to defend CQC.

B

Interestingly, the stories that came back to me are some people felt under.

B

Pressure and unable to do that, but the vast majority was of support for what we.

B

Had been saying,, this speaks to the points that you were making earlier Robert.

B

Actually, if you've got it wrong, admit you've got it wrong and say you're going to put it right.

B

What people connected to and what staff felt able to identify to the in the.

B

Main was that narrative.

B

But, the confidence point is our staff need to be confident when they're.

B

Going out to be challenged to do the job, we're asking them to do.

B

So I think that's one of the ways it washes back,. That's not really part of the.

B

Narrative that we need to continue.

B

On this issue about workloads and pace etcetera, I'm, probably as impatient as.

B

Anybody around the table about getting this done,, but with the best will in the world we're trying to move 2,000, people,, 44,000 different sets of interactions and.

B

A system which is less than five months old and the thing I've learned over the.

B

Years about change is, if you don't do it properly, it won't be sustainable and you.

B

Take out some key ingredients and it will just fall over and therefore I think.

B

Building sustainable change is a balance that we're trying to make,, so I think it is.

B

My job David, with the senior management team and with you at the.

B

Board, to have this conversation here about what the balance is between pace.

B

And sustainability of what we do and that will constantly be needed to be crafted.

B

And tested, I, don't think, there's a,, you're, right or wrong on that, I think it's.

B

A continual dialogue we need to get in place,, that's what we're committed to do.

A

≫≫≫ I think we've got the 18 new inspections, starting from September,.

A

Given where we were looking back a few months ago,, that's not bad, the fact that.

A

We've got the surveillance model in such a state that we feel we can publish the.

A

Results by the end of September.

A

I think there is a lot of progress going, on.

A

I think when you go -- when you're moving from the generic model. To this.

A

Expert model: it means every single employee who works for CQC, virtually.

A

Has a complete change in their job, so it isn't just going to happen. Overnight.

A

But I think by March,. If we roll the clock forward to March of next year, the.

A

Organisation will have the three chief inspectors all in post, the whole.

A

Organisation will have shifted from a generic regional structure to a functional.

A

Structure,, that is a pretty quick work. I think.

A

So I think the next six months, we're nearly there, but not quite there. Yet I think.

F

≫≫≫ So sorry just a very quick point, not for a long discussion necessarily,, but on.

F

The risk register I think there is also risk that you must have discussed before.

F

Which is about respect of NHS staff,? So not just public confidence but respect of.

F

The staff who are being inspected.

F

I think that's quite crucial because they are 1.2 million and care staff as well,.

F

They are also the public.

F

So extremely important to be mindful of that.

B

≫≫≫ Thank you it's public,, professional and political.

B

I think there is all three components that we need and the respect of our staff as well.

G

≫≫≫ On the way that we cut the risks to Michael's point as David picked up. We.

G

Do have a separate risk register that tries to get into some of those crunchy.

G

Issues rather than the strategic level, but the question: is it hospital's, failing and.

G

Hospital inspection,, they are definitely two of the top risks,, but I need to keep.

G

Reminding it is genuinely all our sectors, as opposed to just acute hospitals,,.

G

And on Camilla's point about public confidence because I oversee the.

G

Communications team as well,. They are asking exactly this question because it's.

G

A real tension that they feel they have messages under the previous regime as.

G

To what their role may or may not have been, what I'm trying to say to them and.

G

We're all saying, as an executive team, if we are serious about putting the public.

G

At the centre of everything we do,, it is legitimate to know what the public think.

G

Of us,, so I think it is right that we should measure it,. But what matters to me is the ordering.

G

So, if we ever did it where we started from the perspective of what will look.

G

Good and then tried to tell people about it, that is completely wrong,. What I want.

G

Us to do is do the right things, but it is completely legitimate to professionally.

G

Explain that we have done them, and so when we had Mike's arrival, the right.

G

Thing to do was to prepare for that and to get the list of 18 Trusts who we're going.

G

To go into in wave one but I was pleased with the team because they professionally supported Mike. To get that message across and that's where we.

G

Need to just keep landing,. This is in the about managing of a reputation,.

G

It's about doing the right things and being professional about explaining that.

G

So our thematic activity programme- this is a small number of pieces of.

G

Crosscutting work that we do every year,. We have a variety of thematics so for.

G

Example, we have thematic inspections,, but we also have thematic probes and.

G

Thematic reviews,, so the general term is anything which is cutting across.

G

And gives us an opportunity to rise above what we see at an individual provider level,. Let me pick out three things from this paper then,. There are.

G

Two new thematic inspections that I would ask you to agree for this year,.

G

Which is the dementia work and the transition of children with complex.

G

Health needs from children to adult services,. There is then one thematic.

G

Probe, which sounds a bit like something Mike would have done in his clinical.

G

Practice, but it's in response in part to Camilla's review and looking at health.

G

Care assistants and the training, and two new proposals which we're looking at for.

G

Thematic inspections, one is emergency mental health care and the other is the end of life. Care.

G

In both case, we have given some public commitments but wanted to bring these.

G

To the board for your approval.

A

≫≫≫ Any question for Paul on the thematic probes or reviews?.

C

≫≫≫ The one for transition of children with complex needs to adult services,.

C

I just wondered why we're excluding young people with mental health and.

C

Learning, disability issues, because I don't know,! If thinking about parity of.

C

Esteem, I'm reluctant to say include it, because it would immediately increase.

C

The scope and make it not viable,, but it's a glaring omission.

G

≫≫≫ Let me go away and check, my understanding when I read it was that.

G

Young people who receive care for three or more multiplicity...

G

I'd assumed that included mental health, if it doesn't or if you know.

G

Otherwise, but I can certainly go away and check it,. So it's on 2.1.1 on page 5,.

G

But I can certainly double check. That does include mental health.

A

≫≫≫ Would, you check that and get back to Kay on that will you?

A

>>> Yes absolutely. >>> Okay, thanks. Paul?.

J

≫≫≫ Potentially, these are very important, especially something around end of life.

J

Care because they are cutting across the institutions that we're holding.

J

Responsible for at the moment.

J

What's, going on out there in the health and social care service, is an attempt to.

J

Construct a completely new business model of care around integrated care which cuts across the institutions that we are in our current model, driving.

J

Responsibility into, and that's very, very important that those institutions are.

J

Responsible,, but actually by this time next year, a percentage of care will be.

J

Delivered across those institutions with responsibility above them and in some.

J

Way separate from them. And, we need to prepare for the next revolution, I'm, afraid David, in the way in.

J

Which we do our work,, because at some stage in four or five years, time, we'll be.

J

Looking at integrated care organisations which are across an integrated care.

J

Themes as our main business, and not looking into institutions,, so the more.

J

Practice we get at that with these thematic reviews,. It will be very.

J

Important to be able to do that and be able to judge how to do that.

G

≫≫≫ Thanks,, so when I look in our armoury or whatever non-military.

G

Analogy it is, as to how we can look at integrated care,. This is the best we've.

G

Got at the moment, but I don't think it's enough.

G

So one of the many things we need to do, but on the more externally facing.

G

How is the regulatory world changing and how do we adapt to that, I? Think we'll.

G

Need to develop our strategy, our policy on just how we look right across the.

G

Patient pathway,, as a matter of course, not as a thematic that we layer on top of.

G

Other stuff that we do.

H

≫≫≫ Just to follow on from what Paul was saying,. As you know, I was.

H

Concerned when we identified the kind of general inspection roles,, the chief.

H

Inspector roles not because I didn't think it was a good idea, but because I was concerned, actually we'd lose integration as a consequence and, more importantly,.

H

We'd lose people in the round with all their experience, they'd be cut into.

H

Portions, so I also think this is really important,. It may be the only thing.

H

Available but we need to make the most of it and what struck me when I looked.

H

At this report was two things,, first of all, I suppose, one the importance of starting.

H

With that user experience to define the work which I think is in here, and I, think.

H

It's really critical that before we scope what we do,, that we start with, that.

H

Experience as it's described by people who are in this position,, whatever.

H

Position, it is we're looking at, and the second actually part of the ambition for.

H

This piece of work is not just to learn some lessons about what good looks.

H

Like in respect of these things,, but actually to think about what we can.

H

Learn about some of the indicators would be for good integrated care across these.

H

Various different pathways or different sectors of experience, because those are things we can then build into,. If this is a cross, we can build that back into the.

H

Vertical work, when we look at a hospital, for instance, to see whether or not they.

H

Are set up in a way which is going to create the conditions in which there is.

H

Good integrated care or not,, so it just, the two have to play into each other. I think.

B

≫≫≫ I think both are really powerful points, and this is one way we can do.

B

This using our current methodology,, we had a conversation earlier about.

B

Investigations, they can also do that,, so we can look at dementia care in.

B

West Yorkshire and maternity case in East London to just pull out that point.

B

Mike's job description, Andrea's and whoever wins the interview process.

B

Tomorrow,, all three of those job descriptions have integration built into.

B

Them and we've asked the GP to take a lead on integration, to pick up on exactly,.

B

We're trying to hit a moving target here, it's going to move considerably, and my.

B

Vision for this we'll look at some things where we'll draw staff from hospitals,.

B

Social care and general practice, inspection, teams,, put them together in.

B

Inspection teams to look critically at something lead by one of the chief.

B

Inspectors on behalf of one of the other two or all three of them.

B

So anyway, that we've chose to organise,, it will be an artifact that we'd have to.

B

Deal with, which is how you look across at the reality of somebody's experience,.

B

So if you go chief inspector of older people's services or chief inspector of.

B

Children, you'd still have to cut this, then by institution,. You'd have to do it in some.

B

Way because it'd still be a worry, if I have my hip replaced in Blackburn hospital.

B

Will I get an infection? So? We chose to structure in a particular way, so it's.

B

Absolutely essential that our tools and methodologies and ways of operating.

B

Allow us do exactly that.

B

So, the I think the 14/15 inspection programme will have thematic.

B

Inspections in, but also should have some investigations where we look right.

B

Across the patient pathway care career,, whatever language we end up, settling.

B

On so we can actually take a much more citizen inspired view of what.

B

The reality is, if I live in Blackburn. What is it like to receive health, care and.

B

Primary care services in this town? Are my needs met? Does. This feel.

B

Something that's coherent to me? And, that's the prize. We need to reach for,.

B

But it would be wrong to pretend we're there.

I

≫≫≫ I was going to ask a bit more about the style and nature of these inspections.

I

And whether we were changing them, so I was pleased to hear Paul.

I

Confirming that we've got to do more work in that area.

I

So I think what I would really like to see. Is, we've got a whole raft of work going.

I

On about new inspections of hospitals and all the other institutions that we.

I

Inspect,, are we going to, I? Think Paul confirmed this, we're going to review.

I

How we do this and I think not wishing to add to anyone's workload at the.

I

Moment, I think that's quite important that we do that urgently, because the.

I

Themed inspections are very important and a very powerful tool and obviously.

I

We're increasingly being driven down in themed inspections by requests from.

I

Government and other external factors, so we have to get these up to scratch.

I

Pretty quickly, so I'd just like to know what the planning for that is?.

G

≫≫≫ So, on the basis that pretty much everything else about our model is up.

G

For grabs,, it would seem strange to have anything else,, an expectation that it can.

G

And should change. Yesterday I appointed a new director of intelligence who would lead on that.

G

Emma Rourke from within the organisation and currently leads on the.

G

Themed inspections so, as she develops her programme, I'd be quite surprised if.

G

It didn't have this element because I know it's one. That's close to her heart.

L

≫≫≫ I meant to say to you Paul: when I got the board, papers; I haven't seen any.

L

Of the results of the HCA thing that relates to my review, so I'd love to see them.

G

≫≫≫ I, don't think we've put the results out, but if there is anything, I'm sure.

G

There's things we can share,, we had over 1,000 surveys carried out.

L

≫≫≫ I think you know: I was quite nervous about the first version of the probe,. That was before your time. I think.

L

So I'm interested to see how it's improved since then.

F

≫≫≫ This thematic activity. It may be a good idea to think about focusing some.

F

Of it on areas that the surveillance system is going to develop later, on,.

F

So primary care, for example, if you can't develop the system later, then actually a.

F

Thematic review could be something that could help.

F

And, the only other thing about integrated care,, you might think of.

F

Looking at the pioneer programme,, because that could be a really good.

F

Advanced set of integrated care, systems.

A

≫≫≫ Right, Paul I think it's you again: strategic partnership, plan.

G

≫≫≫ Thank you.

G

Item 12, again. This is something we touched on earlier in the board. Meeting,.

G

About the fact that we need to balance off the fact that we're an independent.

G

Authoritative voice in the system,, that does not mean we have distance from.

G

All our national partners,, so by way of introduction to this paper, we focus on,.

G

At a national level,, 6 other arm's length, bodies or regulators,, the list.

G

Of which is in the paper,, but my colleagues in Healthwatch England,.

G

Monitor, TDA, NHS, England, NICE and the professional regulators, including.

G

Gmc and NMC, and in each of those cases, we're developing memoranda of.

G

Understanding and what I would say is that the memoranda of understanding.

G

Have elements which are quite high level, they are nice,, explain what we are.

G

Doing,, they are underpinned by joint working protocols and really importantly,.

G

By the information sharing agreement,, because that's one of the cornerstones.

G

Of where we know, we need to get better from Robert's work and elsewhere.

G

That is underway,. The paper gives more detail on where each of those is.

G

I wanted to update the board as well on the work we're doing with the Royal Colleges who, colleagues. I have met a number of over the last week or two,.

G

And we've developed a shared memoranda of understanding, we're.

G

Working with the Royal College of Physicians, I met them last week with.

G

Our perspectives of what that could look like,, they have that,, are very positive.

G

About what we've done,, making some changes, which they say, they'll get back.

G

To us for tomorrow, and the aim there would be to have something short that.

G

All medical royal colleges at a minimum can sign up to, alongside us,.

G

I think it's a powerful statement of the way we'll work together alongside.

G

Bespoke memoranda of understanding for the individual colleges that will.

G

Then reference the individual bits of work.

G

And the reason why that's important,, there are a number of things we can do.

G

For them, but just to focus on what they can do for us,, they have a wealth of.

G

Information and intelligence,, including from their clinical audit and assurance.

G

Programmes,, which is very helpful,. Secondly, they are able to give a level of.

G

Professional endorsement, if they are confident in our approach, which then.

G

Goes to the wider staff endorsement,, which is important for the work, we're.

G

Doing and the third is,, starting with Mike's area,, they will be able to support.

G

Us in providing clinical experts for our indepth intensive inspections, so we take.

G

This very seriously with the Royal College,, so I wanted to bring it out alongside our arm's length, body work.

A

≫≫≫ Do, you want to comment on that at all. You've been involved in some of the discussions with the royal colleges?.

E

≫≫≫ Yes, the good news from my point of view is I know most of the royal.

E

Colleges quite well from my previous work,. They are absolutely critical to what we are doing.

E

I think they are really up for this too,. That's been my impression and I think.

E

One of the specific areas that we can work on is in the accreditation.

E

Programmes that they are quite often doing, which may relate to a specific.

E

Area of healthcare like endoscopy, or something like that,, because if we can.

E

Accredit those accreditation programmes,, we will then be able to.

E

Take their work and build it into both our surveillance and our inspection, so we.

E

Would then only need to inspect by exception,, so I think that's where it will.

E

Be really valuable.

A

≫≫≫ And also into how we rate services.

F

≫≫≫ I thought this was great,. It's a dizzying array of MOUs, I. Suppose the.

F

Issue is getting all the MOUs sorted and agreed, and everything at national.

F

Level and then the local physiology, of how it's working, so to get some flavour.

F

Of that, at a regular point, here, I think would be really useful.

B

≫≫≫ That's absolutely right.

B

The only thing worse than reading, a dizzying array is to write them.

B

I think you're absolutely right. The issue is this: is an applied science, not a.

B

Theoretical science,, this really is about whether the CQC inspector speaks to.

B

The regional person in Monitor about hospital X, whether the inspector speaks.

B

To the local authority about care home Y and the concerns about quality.

B

I think it's important that the information sharing protocols are the practical tools.

B

≪Font color = #FFFFFF>which sit under the MOUs which are the</font> how to guides, the one I drew attention.

B

To in the chief exec's report,, the one with the GMC is really being championed by.

B

Staff in both organisations, as quite a practical tool that helps them exchange.

B

The relevant information at the right, time, but I think David. Perhaps one of the.

B

Things that might be helpful is at a future board meeting whether we might give a.

B

Slot to an inspector, and maybe one of the managers to come and speak to us.

B

About what they do, so as well as getting stories from people that have used.

B

Services, get stories from our staff and just ask them to talk about how they're.

B

Applying that and how they're doing that.

B

We know, we need to have a schedule of auditing this and checking out. This is.

B

Something that's robust and check that out with our colleagues, but that might be.

B

One way to do it as well.

G

≫≫≫ On, the local, I think there is three points of interaction,. The MOUs can only.

G

Really do the national stuff and then, as David said, there's the one to one.

G

Interactions with our TDA colleague on the ground in north London or whatever.

G

It might be,, but the other part, in the architecture of the system, with the.

G

Quality surveillance groups, is just how we interact on those groups.

G

Now I went up to see one in operation last week, I was completely struck by.

G

Two things,, so first it was how reliant they are already on our information and.

G

They seek assurance from us,, which is fine and good,, but it's helpful for us to.

G

Know that there is a lot of reliance,, but particularly when it's the interface.

G

Between health and care, is an observation.

G

But, the second part is they are a new body set up from April this year and the.

G

One that I observed didn't have yet and I suspect it's true. In others, there wasn't a.

G

Coherent risk framework,, so there was a lot of discussion about what are you.

G

Doing as a CCG,, there are many CCGs around the room,, so I think it won't be.

G

Through MOUs, but a practical change on the ground as we roll out our local as.

G

Well, as national surveillance;, what do we worry about locally and regionally?.

G

By, sharing that, with the quality surveillance groups, I think we can provide a framework for the system and alignment on what we should collectively.

G

Worry about which begins to answer. Are we going in the same direction and how.

G

Do we avoid missing stuff? So, that's the third leg of this.

B

≫≫≫ So the select committee David. We were asked about document retention by.

B

One of the MPs, we said we'd do some further work on that,. This is that work.

B

So, what this work will do,. It's an audit which allows us work out whether.

B

Our policy is consistent with international standards of document retention and.

B

Then we'll audit, against our current standard, whether we're keeping our.

B

Records for the length of time that we should.

B

The issue was: how long do we keep e-mails was in the Grant Thornton.

B

Report,, that was a line of questioning at the inquiry,. We keep them for a year,.

B

We keep our records for 7 years,, so the question is, is our behaviour consistent with that policy?.

B

And, actually, the only way to check is to do an audit, so this is what this is I'm.

B

Asking to you agree this audit.

B

The Terms of Reference are there,. The audit will be completed over the.

B

Summer,, so by the time you and I are back in front of the select committee for.

B

The accountability meeting in October, we should have an answer about how.

B

Compliant, we are with our own policy and whether that policy is a good one.

B

And it should be better than it is.

B

So I'm asking you to in effect note: that,, that's executive action, I'm taking but I.

B

Think it needs to be reported: here., >>>, Okay, everyone?, Yes?, >>> And. Then second, one is the contract award,. My delegations are.

B

Whatever this figure, I can't remember,, this is above that figure that I can't.

B

Remember it is for 1.4 million and it's to extend the CRM, which is our client.

B

Database in effect, a system within the organisation, to extend it for a further.

B

Two years, this effectively keeps us with the same provider that was recruited by.

B

The Healthcare Commission, going back prior to CQC's creation and I'm, asking.

B

For your agreement on this to date, to make the necessary arrangements to.

B

Award the contract from the autumn of this year.

B

Finance colleagues have recommended this to me and I recommend it to you for agreement.

N

≫≫≫ Okay, yes? >>> Sorry to prolong things, but I do have one question,, which is I'm sure.

N

There are good reasons for it, but I was intrigued that we are embarking on a.

N

Series of relatively short-term service contracts of two years extended by a.

N

Further year, another two year, contract, now that does a number of things,.

N

It pushes up our procurement costs because we have to have a significant.

N

Retendering process every two years,: it also makes it less likely that we'll gain.

N

The advantage of the capital investment by the contractor in the hardware that.

N

They're investing in because they will need to amortise that over two years.

N

Rather than over three or four and therefore we're paying for that extra.

N

Cost, now there may be other valid reasons for doing the two-year rather.

N

Than a three or four-year contract to with flexibility and our changing requirements,.

N

And not getting locked into a structure which we want to change at variation or.

N

At considerable cost, a little further down the line.

N

All I'm really seeking is an assurance that those choices were properly.

N

Considered and the best conclusion for the commission emerged from that,.

N

Rather than it not being considered, or it just being chosen because last time it.

N

Was two years or whatever, and you may not be able to answer that question.

N

Now, but I'm not seeking to hold it up,, but I do think it just, questions did raise.

N

In my mind about why it was such a short contract.

B

≫≫≫ I can't answer that. That's the straight answer to John's question.

B

But, hopefully, in the next few days, we'll announce a director of corporate services,. We need to be aware of investing heroic ambition on all these.

B

People we are bringing in,, but this is an area that needs looking at John,.

B

In a pretty cold, way, and I think getting somebody in new to look at this will be.

B

Incredibly, helpful and I think the person we'll award the job to I think will be able.

B

To bring that objectivity to exactly this issue.

B

My take is I, think we're slightly cautious of commiting to big IT programmes and.

B

That's what's reflected in this, rather than a higher form of strategy about it.

B

I think this issue about how we support predominantly a home-based workforce.

B

Is really the question to get the new director of corporate services to begin to.

B

Answer and there'll be a HR system support dimension to those,, not just.

B

Looking at the kind of hardware, stuff and I want to take a broader look at that.

B

I think the previous audit plays to this as well,. How do we warehouse data?.

B

How long, do we keep it? Where? Is it kept? How? Do we get access to it?.

B

I want us to look at an individual case, we're going to have to get iron mountain.

B

Records out of a store somewhere in the north, this is not the way to run a 21st century. Organisation.

A

≫≫≫ David, could you just put the question to the team why we went for a.

A

Two year contract and not a longer one, as long as they've considered the.

A

Question and have got an answer to it.

M

≫≫≫ Do, you want me to answer that. Now?.

C

We did go through a process of saying the current software and hardware.

H

Model underpins our current regulatory model and approach to registration and.

H

Compliance,, we know we're embarked on a major transformation programme of.

C

Reviewing the regulatory model,, it would be an ill investment to make a long term.

H

Commitment to a major IT system when actually we're at the beginning of that change, programme.

A

≫≫≫ That's fine. Camilla.

L

≫≫≫ Maybe I'll ask Hilary,: this is a fee for hosting a database. That's already.

L

Been built, half a million pounds a year to continue to host a database,.

L

Is that right or are they doing anything else?.

B

≫≫≫ Providing some support as well,. If we need adaptations to the database.

B

Or we can retrieve things. There will be a number of questions, that performance report that we've had,.

B

One of the reasons it's iterated so many times is each time. There's a different.

B

Question asked about how to access it. Somebody needs to commission a piece.

B

Of work so there's been a whole sequence of releases around CRM.

B

The best way to do this, Camilla is my understanding. We needed to redesign.

B

This when we took on the responsibility for registering GPs,, so that was largely.

B

On a digital platform,, the people that did the amendment to the database were.

B

Crm and we buy that service,, we buy a design,, build and operate service off.

B

Them in effect, our role is the intelligent client rather than we do the amendment.

L

≫≫≫ But they're charging us a fee every time we want to slightly change the way we use it,, presumably we've compared this cost to other hosting databases and.

L

We are satisfied that it's reasonable are we?.

M

≫≫≫ We're satisfied it's reasonable in the circumstances.

L

≫≫≫ Right okay.

A

≫≫≫ I'm not sure that matters very much.

A

(Inaudible) 15,, oh Healthwatch,, Anna.

H

≫≫≫ Thanks very much,, it's a long, report, I only want to say one thing and.

H

Then I want to show you one thing. The. One thing I want to say is one of the things that I think we've become.

H

Increasingly clear about as an organisation is that we always need to.

H

Start with consumers, people,, it would be a travesty if we, all bits of system.

H

Didn't do that,, that's what we're set up to do,, so two bits of work that we're doing.

H

At the moment, one around complaints and the current phase of that work is.

H

Very focused on engaging with people's experience through Local Healthwatch,.

H

So this is a way for us to test how this network can work. Together, deliver some.

H

Real value added by putting stories together from across the country.

H

It will be the first time we've done. It, we've done webinars with Local.

H

Healthwatch already, which is yielding rich information about what the issues.

H

Are in complaints and also what the issues are with the processes.

H

Around complaints,, so both dimensions.

H

The annual report, which will be published on October, the 9th, will be.

H

Focused around this notion that actually, we need to develop much more of a.

H

Sense of rights, expectations around health and social care, and in order to do.

H

That we are doing again some research, this time, some research with consumers.

H

And users of health and social care,, so we had a very big deliberative event, a.

H

Couple of weeks ago,, which was fascinating,, we asked people what they.

H

Thought, expectations, things they ought to be able to get from health and social.

H

Care,, what they thought their rights were,, they started on a journey feeling.

H

That, actually, they probably didn't, have any,. They were probably kind of right,.

H

But they ended up in a place where they thought. Actually, we should get this and.

H

Should get that- and this is a slightly different place.

H

That work will form the basis, the structure for our annual report to.

H

Parliament and we'll want to collect and collate how well the system is doing.

H

Against the core expectations, so that again is starting with consumers and users of services.

H

We commissioned for our annual conference a short video of people.

H

Talking about what they wanted from Healthwatch and Local Healthwatch and.

H

I just wanted to show you that if you don't mind,, it's only a couple of minutes,.

H

Part of the reason I want to show you is to give you a sense of what people.

H

Are expecting, what the general public are expecting from Healthwatch as a.

H

Network, but B, I want to crave some support from you, because having got.

H

This DVD, which we're making available to Local Healthwatch we're really keen.

H

To get it out there as widely as possible, so if you have thoughts about ways in.

H

Which it can be more widely distributed both to system players who don't always.

H

Know about lLocal Healthwatch,. Some CCGs are not as au fait as they.

H

Should be about Local Healthwatch,, but also to consumers and users of health.

H

And social care,, it's kind of a resource we'd like to make available to people to.

H

Talk about what Healthwatch is and people can expect, I think the team will.

H

Just play it for us.

H

≫≫≫ When, it comes to health and social care. We all want the best services we can get.

G

≫≫≫ Whether: we only need help now and again.

C

≫≫≫ Whether, the quality of our lives, is affected.

L

≫≫≫ Whether, it's a matter of life and death.

M

≫≫≫ Now through Healthwatch, we can make a real difference to the way.

F

These services are run.

J

≫≫≫ Healthwatch gives us a voice, even for those who sometimes may feel left out.

L

≫≫≫ They listen to our views about how we're treated and how we're cared for.

G

≫≫≫ And they've got the clout to do something about it.

A

≫≫≫ They'll help us shape our local services.

A

>>> And armed with our evidence, experience and stories...

C

≫≫≫ They'll ensure our voices are heard and responded to on a national level.

H

≫≫≫ It's good for us to provide services too.

J

≫≫≫ As Healthwatch can tell us what really matters to people who use our services.

H

≫≫≫ And, at a time where there are so many big changes to NHS and social care.

J

≫≫≫ It's, a comfort to know Healthwatch are there to shape those services.

G

≫≫≫ To see what's working and what's not.

C

≫≫≫ And to champion our needs: too.

C

>>> So we're treated fairly.

F

≫≫≫ With equal access to the help we need.

F

≫≫≫ Healthwatch is independent.

K

≫≫≫ Because they're, not part of the service we provide...

K

>>> That, gives us a trust to be honest with them.

M

≫≫≫ This is our opportunity to be heard...

M

>>> And for us all to learn.

D

≫≫≫ I can make a difference.

H

≫≫≫ I can make a difference.

H

>>> We can make a difference.

H

≫≫≫ So, the only thing I'd add, is that clearly that's a big ambition for.

H

Healthwatch and we're not the people who can do much of what they want us.

H

To do,, but this was in people's own words and what they see Healthwatch.

H

As, is a vehicle for helping them to achieve some of that, now the way that.

H

We'll do that, of course, is by challenging and advising other bits of the system.

H

Nationally and locally to do what they would like to see. Done.

H

But, it is what people want to feel they've got in Healthwatch nationally and locally,.

H

And I think a better way to talk about what we might be able to do if people.

H

Speak, use the channel of Healthwatch to speak to the system, than us, telling it.

H

Ourselves, so happy to take any questions on the rest of the report.

A

≫≫≫ Thanks very much Anna I, like that actually, really good.

C

≫≫≫ A couple of points, we've got Healthwatch England and we've got.

C

Local Healthwatch and yonks ago, before it was Healthwatch, there was a.

C

Debate about individual and collective voice,. Are we championing --.

C

Is Healthwatch championing collectively at a local level, or is it actually helping.

C

Individuals assert their rights and make a complaint?.

C

Because that I know originally was going to be the focus that it would be about.

C

Helping individuals that had a problem and helping them raise concerns and.

C

Make a complaint, so I'm just wondering is that changed,? Is it more about.

C

Involving local communities and them influencing local services,, and it's not.

C

About helping individuals that that's definitely not what it is now?.

C

And, the other thing is just to ask about the setup stages of Local Healthwatch,.

C

Because I can see, you've got quite a good working relationship with the local.

C

Government association, but it's still a significant concern- is funding of Local.

C

Healthwatch, some seem okay, but others seem woefully underfunded,.

C

I know we can't influence it directly,, but it would be helpful to know where we.

C

Are in the set up of Local Healthwatch,, but also what role the funding is going to.

C

Play across the country?.

H

≫≫≫ One of the ways in which -- we're talking about local Healthwatch having.

H

Three particular functions if you like, which I described in my contribution at.

H

The national conference, they are to take what they learn from being engaged with.

H

Their communities and coming to them and make sure something happens,.

H

That could be at an individual level, but it could also be at a collective level,, not.

H

Specified,, it is to take something which it is clear, is a big issue in their community.

H

Which might come as a result of looking at, for instance, the data that comes from.

H

Public Health England cut down to local perspective, to see where the issues are.

H

In their community,, so it might be a top down identification of an issue which in.

H

Local terms needs addressing,, regardless of where the people are coming and saying they need it to be addressed,. So there's a kind of proactive.

H

And a reactive function,, but both really are mostly, as you describe about trying.

H

To make the system better for everyone,, albeit occasionally focused on an.

H

Individual experience. And there's a third one, which is much more focused on individuals, which is the.

H

Signposting function, which is much more about empowerment,, about giving.

H

People, the tools and techniques and information they need and the education.

H

Potentially, they need in order to be able to use the information and find their way.

H

Around the system., There are those three things, now there's a fourth element, which is.

H

Commissioned at local level, which in some cases is commissioned to a Local.

H

Healthwatch also, but in many other cases is not and that's what was the old.

H

Complaints advocacy function,, which is the bit of the system that delivers.

H

Support to individuals in order to pursue their cases.

H

So we've got a very mixed economy in respect of that position and I think one.

H

Of the things that's coming out of our complaints, work is the sense that actually, the situation is worse than perhaps it used to be where we had a.

H

Small number of providers for advocacy services up and down the country,.

H

So there may be something, so watch this space,. There may be something that.

H

Needs to happen in respect of that.

H

So. The picture in relation to individuals is a bit. Bitty is the honest answer to your question.

H

But to move to where we might get to, one of the things we're doing at the.

H

Moment is creating literally a series of maps of Local Healthwatch as we're.

H

Finding out more about them- and it's true to say some are still very much in set.

H

Up, some don't have chairs or boards or don't have directors,. So, whereas others.

H

Are streets ahead doing great stuff.

H

So, the mapping will include such things as which of them do have advocacy.

H

Functions alongside their Local Healthwatch,, so we'll get that picture.

H

Very shortly,, that's a question. We're asking at the moment.

H

It will also be a mapping of funding. So we'll know what the budgets of each.

H

Local Healthwatch is.

H

Just before I talk about how we might use that, the picture actually is that.

H

There are many Healthwatches have got considerably more money than was.

H

Originally identified as the kind of target figure, so lots of local authorities have.

H

Found other pockets of money, particularly in the set up period and.

H

Other activities which they want Local Healthwatch to do,, so it's not,.

H

By no means all bad,, but we know there are one or two examples where the budgets were extremely low.

H

So. One of the projects we've got with LGA is working with Local Healthwatch.

H

To define what good looks like,, what a standard of good practice might look like.

H

In relation to Local, Healthwatch and I think if we can in due course, certainly.

H

By the end of this financial year, begin to map against the funding,, we'll get a.

H

Picture of whether there is a level of funding below which you cannot do it,.

H

Which I think will tell a story which we in the LGA will want to discuss and think.

H

About how we might raise through our various mechanisms,, but it wouldn't be.

H

To say this is the budget. You must have.

A

≫≫≫ Any other questions?.

J

≫≫≫ You mention about the deliberative event and this being the basis of some.

J

Of your annual report to Parliament, I think if I heard you right what's.

J

Important about that is the beginning of the event. People didn't think they had.

J

Rights,, at the end of the event they did, Parliament has a tendency to think.

J

People, because legislation has been passed, people automatically know their.

J

Rights,, it's a myth that goes around for several hundred years, that Parliament does things.

J

Whereas, actually, there needs to be activity., So I, seriously, think in the annual report, demonstrating that the only way people.

J

Know their rights is to have something like a deliberative event is an important.

J

Intervention in actually realising these rights, rather than simply assuming.

J

They're there and I think Parliament does need education around that and.

J

Knowing how MPs generally want to increase people's rights and experience,.

J

What that deliberative event, is, how it might work in a locality, how that might.

J

Work in a region, I think would be useful for Parliament to understand.

A

≫≫≫ Right.

L

≫≫≫ Are the consumer rights you're, envisaging the same as the NHS.

L

Constitution- or are they different?.

H

≫≫≫ We started with what consumers thought of as their rights, during the.

H

Course of the session we introduced a set of,. There are eight consumer rights.

H

Which are widely agreed and accepted at international, the level of the UN,.

H

They are widely used by consumer organisations, they're, pretty.

H

Unexceptional, things like the right to choice, right to information, right to.

H

Redress, right to voice; those kinds of things,, so we introduced those and.

H

Said how does that match against the work you have done,? Not surprisingly,.

H

Because they're not rocket science, there's a very good match.

H

We're, also having an interesting conversation with a group of people.

H

Looking at the way in which the NHS constitution might be used to deliver.

H

More traction,, of course, our work is across health and social care,.

H

The NHS constitution is only NHS,, but we did with that team. A mapping of the.

H

Nhs constitution against the existing 8 consumer rights, and what do you know.

H

There's quite a good fit, there's some gaps, interesting gaps which are worth.

H

Looking at and the NHS constitution is a level of microdetail and specificity in.

H

Some of these areas, which is not really helpful because you can't remember the.

H

Detail of that,, but if actually the headline is the right to information, you can.

H

Remember, that,, that's something that is more empowering,, so we're talking.

H

About how Healthwatch can become what's being called an interpreter for the.

H

Nhs constitution,, perhaps building in this broader, over-arching concept of.

H

Consumer rights,, but re-crafted slightly as a result of this research.

L

≫≫≫ That's really interesting; I've, just become very conscious. Lately, people.

L

Are very confused,, they still think there's a patient's charter,, the NHS constitution.

L

I think is really excellent, but it doesn't have much traction and people are not.

L

Very aware of it,, so if we can end up with one thing that would be brilliant.

L

≫≫≫ That's the plan.

A

≫≫≫ Thank you very much Anna, thank you.

A

John, it's for information, I, think.,.

N

≫≫≫ For information I'm happy to answer any questions in the meeting or outside.

A

≫≫≫ Thank you. The board forward plan,, nothing on that Clare I think?.

A

Right any other business?

A

Sorry. Yes, the gentleman at the back.

O

≫≫≫ David described me as his proof reader for his paper in coming here. As.

O

Healthwatch, actually I've come here today from a small community group.

O

Called Kingfisher in Gloucester, really, and I ask permission if I could come.

O

Really, because I know everyone else is busy around the table, but today they're.

O

Exceptionally busy with 200 children, their summer activity, week, many of the.

O

Little children are known or referred from social services and for a great many that.

O

Will be their holiday for the week really,, so I purposely asked permission to.

O

Come today, really. I really liked Robert's point about getting out there and talking to people, I. Think.

O

It's a very obvious thing to do,. There is a bit about how you do that as well, and.

O

The timing of that and again making sure when we do do that, make sure it's.

O

Effective both for the person we're speaking with and also the organisation really.

O

You described Robert's report as seminal really, and I just wrote: down, immense.

O

I've had the pleasure of hearing Robert speak about the report on a number of.

O

Occasions and what I really like about it, is it's an absolutely immense report and.

O

Delivered by an immense person as well with that passion and commitment.

O

Behind the words.

O

For me,, what I heard today was a lot of discussion around CQC in terms of the.

O

Very corporate level, but what I was really pleased with was the interjections.

O

Around actually, what does it really mean at a local level.

O

What, does it mean when I speak to someone in Gloucester,.

O

Or Gloucestershire or other people from other Healthwatches really,. What do they.

O

Tell me about the trust and integrity that they actually feel from the Care Quality.

O

Commission, so I think overall, for me it's great nationally, but actually really my.

O

Focus is what does it mean and what is the impact locally really?.

O

I wanted to join a few of those things up if I may,, one of the things that I was told.

O

To do today by people at Kingfisher was to pass a message to Kay, and that bit.

O

About getting out and seeing people and Kay, we've been very privileged to have.

O

Kay come down and see 200 people with learning disabilities at their disco.

O

Evening, and the sort of things that get fed back to me is how easy Kay fitted in.

O

Really, how easy Kay felt welcomed,, so one of the things I ask with the.

O

Commission and to Kay, is: what would you like me to say, and what they clearly.

O

Told me to say and Jan who leads a lot of this work at Kingfisher said. Is you.

O

Give Kay our love, our best wishes and our thanks,, so I've done that.

O

The other thing, I picked up from Kay, as well, I picked up many many times from.

O

Just listening at the board, really, was the word culture.

O

I heard that a number of times- and we know it's not easy to change,.

O

But actually we know what we know as well, and I think the words that Kay said.

O

About the fact that she didn't feel that that was going to change or was.

O

Changing, it was going to change,, she would be there. Really.

O

I jointly co-chair the Care Quality Commission's quality group with Kay,.

O

I'm very privileged to do so, I'd, actually echo those words as well,. If I didn't feel.

O

That that actually we've set things in place, now, and yes, we'll have to test.

O

Them, and yes, they will be challenging, but we have to achieve them and I.

O

Certainly will be there in that role.

O

So, thank you for listening to me, I've done my job, feedback to the people,.

O

They will say what did you say Bryn, so we have a video to prove it. So thanks.

O

Also, what I like about the culture really is in terms of the openness, you open.

O

Up for people to come and literally have a say and I think they are very, very.

O

Powerful messages,, so it's not just words that we say,. We have a public.

O

Meeting,, but you invite the public to have a say, and that, for me, is an.

O

Exceptionally,, exceptionally powerful message.

O

A

≫≫≫ Bryn you're very welcome to come any time you want and thank you very.

A

Much for the contribution you made and feel free next time to chip in during the.

A

Meeting, if you wish to do so and very much noted the comments you made.

A

About Kay as well, we're delighted that Kay is with us for the next three years.

A

Anyway, Kay, that's terrific, as well.

A

So. Thank you very much for coming. Just before I close,. One thing I should have just said: that's that John Lappin.

A

Not all of you know,, but he retired, from the board last time,. He just wanted me.

A

To make it clear he was retiring,, he wasn't going as a result of the.

A

Grant Thornton report or anything like that.

A

That's it I think, we're going to have a quick lunch and reconvene at 2 o'clock,.

A

Hilary is that all right for to you do at 2 o'clock?.

A

I think we'd rather get on with it please.

A

Good, thanks very much., Robert I should also thank you very much and thank you for bearing with us.

A

For the rest of the meeting as well,, thank you very much., Thank you.

A

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