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From YouTube: CQC board meeting – May 2019
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A
Right
good
morning,
everybody
welcome
to
the
May
meeting
of
the
public
board
and
we
have
apologies
from
Jorah,
Gil
and
Malta,
both
of
whom
are
abroad.
I
want
to
welcome
Amanda
Haynes.
Today,
Amanda
is
the
chair
of
our
disability,
equality,
Network
Amanda.
Do
you
just
want
to
very
briefly
introduce
the
network
to
people
you
made
to
put
your
microphone
on
I'm.
B
The
chair
of
the
disability,
Equality
Network
for
colleagues
within
CQC,
and
we
engage
with
regularly
with
about
160
colleagues
that
we
know
about,
but
we
also
understand
that
there
are
a
number
of
colleagues
which
don't
register
with
the
network
and
but
we
do
not
exclude
those
from
any
of
our
literature,
so
we're
really
out
there
being
in
post
for
three
years.
But
my
day
job
is
I'm
an
inspector,
so
I
inspect
dentists.
A
Thank
You
Amanda
you're
very
welcome
to
the
board
meeting
today.
I
also
need
to
welcome
Katie
Roney,
our
chief
inspector
of
adult
social
care.
You
were
here
at
the
last
meeting
as
an
observer
you're
now
here
properly
in
your
own
right,
you're
extremely
welcome
right
that
takes
us
onto
declarations
of
interest.
As
anything,
anybody
needs
to
declare
very
good
minutes
of
the
meeting
of
the
24th
of
April.
Are
they
a
true
and
accurate
record
of
all
we
discussed
excellent?
They
are
therefore
approved
on
the
action
log.
There
was
one
item
which
has
been
completed.
A
C
Peter
I'd,
like
to
begin
by
talking
about
our
response
to
the
Public
Accounts
Committee
board.
Members
will
will
recall
that
the
Public
Accounts
Committee
conducted
an
investigation
into
the
CQC
performance
in
December
2017,
and
since
then
we
have
written
to
the
committee
to
update
them
on
our
performance.
We
wrote
again
in
April
and
our
copy
of
our
letter
is
available
in
the
public
domain
at
Parliament,
dot,
dot,
uk'
and
it
just.
C
It
goes
through
a
series
of
of
updates
on
our
overall
performance,
particularly
focused
on
on
a
report
timeliness,
which
was
an
area
that
I
know.
The
committee
were
particularly
interested
in
so
happy
to
take
questions
on
any
aspect
of
that.
It's
also,
it's
also
just
an
opportunity
just
to
update
on
our
market
oversight
team.
We
are
market
oversight,
team
I've
continued
to
be
active
and
I'm.
At
the
moment
we
have
no
organizations
at
stage
6
in
market
oversight
stage
6
as
board
members
will
recall.
C
D
C
E
So,
just
to
draw
the
both
attention
to
an
up-and-coming
refresh
of
existing
information
about
people's
rights
to
access
and
visit
relatives
or
loved
ones
within
care
homes,
so
that
will
be
being
made
available
shortly.
The
next
upcoming
report
is
very
much
a
joint
effort
between
prime
medical
services
and
adults,
social
care,
which
has
been
a
focus
on
people's
or
health
care
needs
within
residential
care
homes.
That
report
is
due
to
be
published
in
June.
F
G
Sorry
yeah,
just
from
an
external
perspective
as
well
and
nice
are
obviously
very
pleased
that
we've
we've
done
this
work
and
are
going
to
use
the
the
the
report
itself
to
demonstrate
the
impact
of
their
own
guidance
and
they're
very
pleased
that
we've
done
in
the
very
pleased
that
the
way
we
carried
it
out
and
I
think
that
the
the
evidence
is
strong
around
how
or
how
well
or
not
organizations
have
used
their
guidance.
So
that
they're
pleased
on
our
behalf
or
anything
so.
A
H
On
that
basis,
we
also
highlighted
the
work
they've
done
on
learning
from
deaths
and
the
recent
report
on
that,
demonstrating
that
more
work
is
necessary
in
terms
of
culture
change
in
organizations
to
make
sure
that
learnings
lessons
are
learned
when
patients
sadly
die
and
I
work
on
assessing
mental
health
care
in
acute
hospitals,
which
both
we
thought
were
relevant
to
the
NHS
eating
disorder
services.
The
evidence
we
gave
is
now
published
on
the
committee's
websites.
My
understanding
is
the
moment:
is
they're
not
going
to
have
an
oliveira
following
the
evidence.
C
G
Thank
you.
So
this
is
just
to
make
broad
aware
of
a
new
digital
platform
that
we're
currently
trying
to
gather
the
views
of
people,
youth
services
providers
and
the
stakeholders.
We've
got
a
long
tradition
of
involving
all
those
groups
in
our
work.
What
we
wanted
to
do
is
to
explore
a
new
platform
to
be
able
to
share
more
information
in
real
time
and
also
to
take
comment
on
some
of
the
of
our
reports
and
some
of
our
thinking
as
we
develop
it.
G
So
this
is
very
much
so
fitted
with
the
agile
philosophy
of
testing
and
trying
working
with
each
groups.
We've
had
a
really
strong
sign
up
from
both
people.
You
have
services
providers
and
other
stakeholders
and
we'll
be
bringing
back
to
the
board
the
the
fruits
of
that
through
the
for
the
engagement
that
we
do.
I'm
very
hopeful
that
we'll
it'll
be
in
addition
to
what
we
already
do
around
co-production
and
face
to
face
engagement
with
all
of
those
groups.
But
it
will
happen,
offers
more
in
terms
of
real
time,
engagement
with
an
audience's.
A
C
So
the
next
thing,
the
next
paper
is
the
performance
report
whilst
and
whilst
the
accounts
are
not
are
not
yet
fully
closed,
the
performance,
the
operational
performance,
is
largely
likely.
What
will
land
as
as
written
in
this
report
so
before
I
move
to
in
the
individual
directors?
Just
talk
briefly
about
about
performance
highlights
in
their
area,
I
thought
I'd
just
just
say
a
few
words
around
around
the
performance
story
as
a
whole.
One
of
the
things
that
we
sometimes
forget
is
we
do
around
70
inspections
a
day
in
the
organization.
C
So
so
you
know
what
we
do
is
pretty
high
volume
and
we
sometimes
had
sometimes
forget
that
and
I
think
the
story
of
performance
this
year
is
of
a
gradually
improving
trend
and
being
particularly
in
particular
impressed
with
the
performance
that
the
teams
have
delivered
in
the
final
quarter
of
this
year.
An
individual
inspectors
in
particular
world
will
talk
to
us
about
that
shortly.
I
think
I.
Think
we've
also
got
a
story
here
of
a
change
program
which
has
really
begun
to
crystallize.
C
So
so,
not
only
are
we
working
on
on
so-called
business-as-usual
performance,
which
is
improved,
but
I,
think
I
think
we
are
we've.
We've
made
great
strides
in
in
crystallizing
the
change
activity
which
we'll
be
doing
during
nineteen
twenty
and
we've
seen.
We've
seen
that
starting
to
get
to
a
point
now
where
we've
got
a
clearer
view
of
that-
and
we've
reported
here
in
the
last
few
months
in
particular,
are
on
on
where
we
are
with
that.
C
So
I
think
I
think
some
some
positive
stories
I
think
I
think
there
is
still
some
still
some
challenges
on.
Undoubtedly
I
still
think
we
need
to
do
more
around
making
sure
our
our
reports
are
on
time
and
some
of
those
sorts
of
those
sorts
of
things
internally,
but
I
think
it
is.
It
is
still
true,
though,
that
the
overall
quality
of
of
the
of
the
work
that's
being
done
by
providers
is
improving.
C
So,
in
terms
of
of
the
impact
that
we
are
having
on
people
in
this
country,
I
still
think
it
is
a
positive
and
improving
trend
and
I
think
that's
a
real
testament
to
to
all
of
the
people
that
work
in
health
and
social
care,
as
well
as
as
well
as
our
own,
our
own
teams,
so
without
Peter
I'll
hand
over
to
to
the
to
the
the
director
one
of
the
time,
just
to
talk
to
a
couple
of
words
about
their
performance.
Thank
you.
Thank
you.
E
Okay,
thank
you
so
and
if
I
can
just
start
off
with
a
kind
of
comment
on
outcomes
for
people,
so
very
much
follows
on
from
Ian's
opening
remarks.
So
if
we
look
at
quality
and
adult
social
care
over
the
last
three
years,
you'll
see
a
trend
that
you'll
be
well
well
familiar
with,
which
is
a
reduction
in
inadequate
and
requires
improving
providers
and
an
increase
in
the
number
of
good
providers.
So
so
that's
good
news.
It's
good
outcomes
for
individuals,
an
area
of
interest
that
we
continue
to
keep
our
focus
on.
E
Are
those
providers
about
25%
of
our
good
providers?
Don't
consistently
say
in
that
rating,
so
they
sometimes
drop
down
to
acquire
improvement
and
then
come
back
up
again.
There
is
a
well-developed
methodology
within
ASC
about
supporting
those
providers
who
kind
of
yoyo
back
and
forth
between
RI
and
good,
but
actually
I,
think
there's
more.
We
can
do
around
leaning,
leaning
that
approach
so
there's
an
area
focus
on
that,
but
broadly
outcomes
for
people
receiving
adult
social
care
in
in
England
is
an
improving
story.
E
So
what
you'll
see
in
slide,
16
or
27,
depending
on
which
slide
that
you're
looking
at
is
you'll,
see
that
there
evidence
of
increased
productivity,
so
a
reduction
in
capacity
as
planned,
but
an
increase
in
the
number
of
inspections
that
are
happening,
which
reflects
that
kind
of
leaner
way
of
working.
And
then
final
comment
on
ASC
performance
is
a
real
planned
targeted
focus
on
clearing
the
backlog
of
those.
E
Those
inspections
that
were
75
days
plus
overdue.
So
you'll
see
that
number
having
significantly
reduced
down.
While
what,
as
we
focus
our
efforts
on
that,
so
so
good
news
story
and
progress,
but
still
lots
to
do
to
ensure
that
we
continue
to
hit
that
particularly
that
timeliness
of
reports
going
through
this
this
financial
year.
F
You
Peter
so
in
PMS,
ever
think
in
terms
of
performance
is
generally
going
very
well.
We've
got
92%
of
our
inspection
reports
being
published
within
50
working
days
and
the
number
of
days
that
it
has
taken
to
publish
those
reports
has
reduced
over
the
year
from
31
to
27,
which
is
good,
I'm,
really
pleased
Amanda's
here
today,
as
one
of
our
dentistry
inspectors,
because
actually
our
dental
team
do
a
fantastic
job
and
continue
to
deliver
a
really
high
standard
and
meet
all
of
their
KPIs
and
have
a
huge
program
of
work.
F
So
I'd
like
to
say
thank
you
to
take
the
opportunity,
while
Amanda's
here
today.
Thank
you
to
the
the
dental
team.
We
I'm
keen
as
we
go
forward
to
explore,
what's
happening
with
the
deterioration
of
some
of
our
good
practices.
We
have
a
high
level
of
good
and
outstanding
practices
in
PMS.
If
you
look
at
slide
28,
we
are
having
some
practices
that
are
deteriorating
from
that
position
and
we
need
to
understand.
What's
underlying
that.
So
that's
something
I
want
to
explore
in
more
detail
over
the
next
few
months.
F
We
are
having
a
continued
focus
on
productivity
and
consistency
within
the
within
the
Directorate,
because
I
think
that's
something
we
need
to
continually
work
at
and
improve,
but
generally
we
continue
to
work
with
our
quality
improvement
teams
across
PMS
to
make
sure
that
that
is
continuing
a
continuing,
improving
situation.
So
thank.
H
Thank
you
so,
as
I've
highlighted
before
to
the
board,
we
achieved
our
target
of
number
of
inspections
during
the
last
financial
year
and
we've
made
great
progress
in
improving
the
turnover
of
inspection
reports.
We've
got
to
a
plateau
in
that
now
we're
doing
a
lot
of
work
to
improve
the
process
and
I'm,
confident
that,
with
within
a
few
months,
we
should
be
able
to
move
to
a
much
higher
level
and
and
get
to
the
target
during
the
financial
year.
A
lot
of
work
is
going
in
on
that.
H
There's
a
I'm
very
pleased
with
the
work
or
all
my
inspectors
have
been
doing
at
the
moment.
They're
working
around
standardized
statements,
which
follows
all
very
much
from
the
work
in
ASC,
which
we've
learned
from
and
I
think
there's
a
real
opportunity
to
push
forward
on
that
going
forward
so
that,
in
terms
of
in
terms
of
performance,
that's
our
main
focus
at
the
moment
in
terms
of
the
the
outcomes
full
trust.
If
you
look
at
slide
22,
you
will
see-
and
we
touched
on
this
last
time,
but
just
to
emphasize
again.
H
The
trend
continues
is
that
there
is
a
steady
increase
in
the
in
the
proportion
of
services
that
a
good
or
outstanding
going
forward,
and
this
is
in
a
sector
that
a
where
a
lot
of
services
face
a
great
deal
of
work,
force,
pressure,
workload,
pressure
and
financial
constraints
and
I
think
we
should
pay
great
credit
to
the
frontline
teams
in
those
clinical
services
that
are
driving
improvement.
I
have
no
doubt
that
our
reports
are
an
important
impetus
for
that
improvement,
but
we
said
that
the
work
is
theirs
and
I
think
we
should
should
share
them.
H
We
need
to
do
more
on
that
and,
interestingly,
we
are
just
about
to
publish
a
report
on
a
dependent
health
where
we
make
exactly
the
same
points
that
the
independent
Health
Organization's,
the
acute
hospitals
that
have
improved
have
improved
because
of
leadership
and
culture
and
engagement
of
frontline
staff.
We've
got
some
really
good
examples
of
that,
and
hopefully
that
will
be
out
shortly
too
to
reflect
what
we've
already
found
in
AHS
hospitals
and
mental
health
trusts
as
well
can
I
refer
you
to
page
two
slide
27.
H
This
looks
at
the
ratings
by
different
sectors
within
hospitals
and
the
general
pattern
of
all
sectors.
Improving
is
important,
it
is
there
all
sectors
are
improving
month
on
month
and
every
month
we
see,
we
see,
services
improve,
but
I
think
the
the
biggest
concern
still
remains
around
acute
services
in
acute
hospital
trust.
H
We
are
providing
as
much
support
as
we
can
for
them
to
improve,
but
they
do
have
a
formidable
task
to
do
so,
but
across
the
hot
cost
abort
there
is
improvement
going
forward,
and
if
you,
if
you
turn
over
to
the
next
slide
page
28
you'll
see
what
aware
that
there's
evidence
of
the
last
question
do
the
location
is
rated
good
and
deteriorate
and
I
think
one
of
the
really
strong
things
we
found
is
at
once
or
services
get
to
good
or
outstanding.
They
tend
to
maintain
that
rating.
H
We
don't
see
a
lot
of
services
falling
from
which
do
occasionally
seen
services
whose
rating
two-tier
rates,
but
it
is
not
a
common
finding
and
I,
think
that
is
really
encouraging.
That
services
have
shown
improvement,
have
sustained
improvement
and
a
lot
of
improved
we're
seen
in
previous
times,
has
been
temporary
and
once
the
focus
moves
on
the
the
quality
of
care
deteriorates
again,
but
we
are
seeing
sustained
quality
of
improvements
in
many
services
and
just
going
on
to
the
next
slide,
do
the
replication
rate
of
requires
improvement.
This
is
like
29
improve.
H
The
answer
is
in
hospitals
about
a
third
of
them.
Do
about
a
third
of
them
improve
on
ratings
re-inspection.
Overall,
you
see
it
varies
between
acute
trusts
and
mental
health
trusts
and
independent,
but
it's
about
a
third
overall
it.
Those
that
don't
improve
their
rating
from
requires
improvement
about
half
of
them
actually
get
get.
They
do
improve,
but
they
don't
improve
sufficiently
to
jump
a
rating
and
I
think
they
are
doing
the
right
thing.
K
You
Ted
and
I'm
pleased
that
some
of
the
lessons
learnt
from
ASC
are
being
imported
and
I
look
foot
the
figures
in
two
months
being
better
one
of
the
other
key
lessons.
There
was
also
that,
having
created
the
new
way
of
doing
things,
there
was
a
very
systematized
mechanism
of
communication
and
facilitation
for
implementation
across
the
whole
of
their
Inspectorate
workforce.
Have
you
also
imported
that.
H
Indeed,
we
have,
and
we
were
working
very
hard
on
the
engagement
of
staff
around
standard
judgment
statements
that
we
talked
about
in
the
moment.
A
lot
of
communication
with
them
on
that
and
they
I
think
are
generally
very
welcoming
of
the
approach
so
I'm,
very,
very
hopeful
that
it
will
be
widely
adopted
quite
rapidly.
We've
asked
staff
over
the
the
current
period
to
introduce
them
gradually,
but
we
expect
them
all
to
be
fully
implemented
by
July
when
we'll
see
an
impact
on
performance.
H
L
Thanks
to
a
very
specific
question
and
I
noticed,
there's
been
a
slight
increase
in
Mental
Health
Act
visits
and
I
seem
to
recall
that
last
year
that
been
a
slight
decline
and
it
wasn't
in
there
were
various
possible
reasons
why
I've
been
at
decline
and
I
just
wondered
whether
there's
a
story
behind
that.
If
we've
been
trying
to
make
sure
that
we
up
those
numbers
or
is
there
some
other
reason
that
I
don't
really
want
to
be
assured
that
we're
doing
sufficient
visits
for
people
who
are
in
that
sort
of
fairly
vulnerable
situation.
Yes,.
H
The
and
you'll
notice
as
well
that
the
so
word
will
cheat
we're
not
quite
on
our
target,
but
we
have
improved
before.
What's
on
that
and
again
that's
down
to
the
local
team,
developing
that
in
terms
of
mental
health
doctor
visits,
there
is
a
steady
increase
over
time
and
so
in
mace.
We
may
see
some
ups
and
downs
on
occasion,
but
there
is
a
steady
increase
in
tomorrow.
H
A
M
You
Peter
I'm,
not
I,
was
not
going
to
talk
about
I'll
change
activity.
Apart
from
to
say
that
we've
been
doing
a
lot
of
work
around
building
our
foundations
this
year,
I
think
we've
got
a
really
clear
understanding
of
what
work
is
going
forwards,
timelines
to
deliver
that
and
we're
now
putting
the
resources
in
place.
But
what
I
did
want
to
do
is
just
pick
up
on
our
registration
activity
just
to
highlight
some
really
good
work.
M
That's
going
in
that
space
this
year
and
I
think
it's
starting
to
pay
dividends
now,
in
the
the
back
end
of
this
year
in
terms
of
performance,
but
I'm
really
confident
that
it
will
start
to
really
show
as
we
move
through
the
this
coming
year,
we've
been
really
working
hard,
looking
at
how
our
registration
processes
work
and
how
we
can
really
lean
out
those
processes.
We've
been
working
really
embracing
the
sort
of
quality
improvement
mentality.
M
We've
been
bringing
multidisciplinary
teams
together
to
look
at
very
specific
problems,
runnings
of
two
days,
Sprint's,
where
we've
mapped
out
the
process
and
then
redesigned
it
there
and
then
and
put
it
into
our
and
then
the
very
next
day
put
it
into
a
sandbox
for
testing
to
check
it
out,
see
little
work
and
then
rolling
it
in
to
live,
and
this
has
really
started
to
make
some
difference.
So
if
you
look
at
the
rejection
rates,
if
you
look
at
March
performance
there,
that's
really
shown
a
marked
improvement
as
we
started
to
roll
that
out.
M
We've
got
a
number
of
other
areas
where
we're
working
on
that
for
sort
of
low
risk
registration
activity
where
we're
adding
or
removing
providers.
We've
moved
a
lot
of
work
from
the
inspectors
into
the
national
call
center,
where
they're
able
to
take
a
very
consistent
and
process
driven
approach
to
really
driving
out
performance
there
and
I
think
it's
something
that
we
will
want
to
share
a
bit
more
of
as
it's
a
really
good
way
of
working
and
one
that
we
really
want
to
do
more
of
soon.
As
we
move
forwards,.
N
Thank
Jim
can
I
ask
a
question
on
the
application
volumes
on
slide.
7
I
think
it
is
I
was,
and
you
may
have
advanced
this
question
previous.
You
know
I
forgot
what
the
answer
is,
but
that
we
seem
to
an
increase
from
about.
You
know
roughly
three
thousand
three
hundred
over
the
first
nine
months
the
year
to
around
four
thousand
four
hundred
in
the
last
three
months.
What
was
the
reasoning
behind
that.
M
We
I
think
there's
been
some
common
bragging,
finds
that
and
bring
it
back
to
you,
but
there's
been
some
changing
in
what
we're
actually
registering
so
I'm,
getting
a
lot
more
requests
in
for
for
registering
specific
types
of
activity
or
registered
managers.
So
I
will
get
the
detail
and
let
you
know,
but
it's
it's
staying
constant
and
we
haven't
increased
our
resources
to
deal
with
that
as
well
staffing.
That's
it
that's
an
important
point.
Just
like.
J
J
Within
that
there
and
we
we've
exceeded
expenditure
by
2.9
sandwiches
within
our
2%
KPI.
We've
also
had
a
surplus
on
income,
a
4.4
million
which
is
2%.
So
that's
a
combination
of
growth
in
certain
sectors,
but
also
as
a
chunk
of
that
is
just
around
accounting
treatment.
So
it
kind
of
masks
the
yeah,
the
overspend
on
on
expenditure
in
the
under
spend
on
income
over
all
the
surplus
of
1.4
million
subject
to
end
of
you
ordered.
A
O
D
Thanks
very
much,
first
of
all,
thank
you
very
much
to
all
the
chief
it.
So
it's
obviously
thinking
carefully
about
the
issue
of
improvement
since
our
discussion
last
time
around
and
that
that
conversation
was
partly
prompted
by
the
performance
report.
Looking
like
it
didn't
the
figures
didn't
change
very
much
from
one
reporting
time
to
another,
and
and
because
of
that,
the
I
must
that
I
asked
our
performance
people.
They
could
give
me
some
more
detail
behind
the
figures
and
and
they
they
did
that
so
I'm.
That
was
very
helpful.
D
An
assessment
I've
got
much
more
detailed
information,
and
this
is
an
area
I
think
in
the
next
phase
of
CQC
strategy,
which
I
think
we
do
need
to
be
thinking
quite
closely
about
because
it
it
does
tell
a
slightly
different
story
of
the
from
the
one
of
constant
improvement
that
we've
just
been
hearing
about,
and
it's
it's
not
a
bad
story.
There
has
been
improvement,
so
it's
in
those.
If
you
look
at
the
ratings
nationally
of
provider
organizations,
they
have
steadily
got
better,
and
that
suggests
that
something
about
improvement,
working
and
maybe
CQC's
contribution.
D
D
The
most
recent
figures
don't
show
very
much
change,
and
one
of
the
reasons
for
that
is
that
I
suspect
is
that
we
already
have
so
many
organizations
rated
good,
that
it's
quite
hard
for
the
figures
to
get
that
much
better
okay,
they
could
get
a
little
bit
better
and
they
are
getting
a
little
bit
better
and
but
but
mostly
they're,
staying
more
or
less
where
they
were
so
we
take
PMS,
for
example,
the
figures
for
the
last
two
to
three
years
are
more
or
less
the
same.
You
wouldn't
really
see
this
much.
D
The
same
is
true
about
social
care.
It's
a
little
bit
different
in
hospitals,
actually
where
there
has
been
a
more
obvious
improvement,
although
some
of
that
is
related
to
a
particular
bit
of
the
hospital
scene,
which
is
specialist
NHS
trusts
which
have
made
quite
a
big,
have
quite
a
big
improvement
so
and
I'm
not
saying
this
just
to
cast
doubt
on
what
people
said.
I'm
just
think
this
it's
complicated
and,
and
some
of
it
is
about
the
way
we've
gone
about
ratings
in
general.
D
We've
got
so
many
organisations
that
are
good,
that
it
makes
it
quite
difficult
to
monitor,
what's
changing
and
and
but,
but
what
we
can
see
is
that
very
few
organizations
having
got
a
good
rating
have
been
gone
on
to
get
an
outstanding
rating.
So
that's
stability
of
the
ratings
that
you're
referring
to
is
it's
not
necessarily
a
good
thing?
It's.
It
suggests
that
not
many
stretch
on
to
the
next
level-
and
there
just
are
a
number
of
areas
of
that
kind.
I
think
we
you
know.
D
These
figures
deserve
a
closer
course
of
scrutiny,
so
this
is
not
to
criticize
any
performance
of
any
sector.
I
think
what
the
evidence
is
that
it
generally
is
good
across
most
sectors.
Most
of
the
time,
it
is
I
think
to
make
us
question
whether
in
the
next
phase
our
approach
is
quite
it
is,
it
can
be
simply
repeated
in
the
same
way
and
understanding
the
change
people
touched
on.
D
It's
going
to
be
crucial
understanding
the
incentive
to
change
in
provider
organizations
and
how
big
they
see
the
hurdle,
how
big
they
see
the
step
up
to
excellence
from
having
got
to
a
certain
level
of
satisfactory
performance.
Those
are
going
to
be
critical
issues,
I
think
for
us
next
time
round
and
I
feel
we
have
skirted
around
this
issue
a
little
bit.
We've
talked
a
little
bit
about
understanding
improvement,
so
we've
got
a
bit
of
understanding
of
it.
We
tend
to
fall
back
on
leadership,
but
exactly
what
is
it
about
leadership
that
makes
those
differences?
D
There
are
some
differences
and
some
questions
for
us,
I
think
which
shouldn't
make
us
too
satisfied
with
where
we
are
at
the
moment.
We
shouldn't
be
too
satisfied
with
the
recent
improvement,
because
there
isn't
very
much.
We
shouldn't
be
satisfied
with
the
fact
that
so
many
places
are
good
because
they're
not
they
seem
to
be
remaining
good,
not
going
up,
and
that
is
something
that
we
we
should
be
prepared
to
address.
I
have
to
say,
I've
been
mentioning
this
a
few
times
and
I
regard
it
as
a
sort
of
personal
sort
of
failure.
D
A
K
A
K
You
know
I
I'm,
not
promising
to
be
the
ghost
of
Lewis
past,
but
I
have
drawn
attention
to
the
way
that
we
present.
The
figures
in
the
past
does
not
necessarily
allow
us
to
understand
if
there
has
been
a
system
changed
as
an
improvement,
as
opposed
to
just
a
month
on
month
variation.
We
should
expect
from
the
existing
system
and
another
been
conversations
about
doing
something
about
that.
I've
seen
some
interesting
work
done
by
Mark
Edmonds
and
his
team
that
would
assist,
and
so
my
question
is
really
picking
up.
H
Yes,
now
I
mean
I.
Think
Lewis
is
right
in
that
we've
been
focusing
on,
requires
improvement,
inadequate
requires
improvement
services
and
they
are
continuing
to
improve
those
services
are
good.
We
have
seen
an
increase
in
the
number
of
services
which
are
outstanding,
but,
having
said
that,
we
wouldn't
expect
a
lot
of
services
scheduled
outstanding.
I'd
argue.
H
That
is
an
important
achievement
and
I
am
more
worried
about
those
that
have
stuck
at
requires
improvement,
as
I
said
earlier
on
the
one
says:
if
she's
not
part
of
a
bigger
trend-
and
there
is
there's
a
there's-
a
kind
of
a
big
discussion
we
need
to
make
beyond
this
to
saying,
if
we're
going
to
define
improvement
purely
in
terms
of
our
ratings,
is
that
sufficient
and
do
we
need
to
look
beyond
their
ratings
to
look
at
improvements
and
I?
Think
that
is
probably
work?
H
A
So
can
I
just
just
add
my
own
thought
on
that
two
thoughts
which
I
think
broadly
support.
What
both
your
Ted
and
Luis
you
you're
both
saying
when
I
did
my
pre-appointment
hearing
with
the
Health
Select
Committee
back
in
2015
I
was
asked
what
I
thought
success
would
look
like,
and
my
answer
was:
every
service
was
was
good
or
better,
in
other
words
that
you
know
actually
that,
but
that
that
that
would
mean
that
was
nothing
that
we
were
responsible
for.
That
was
requiring
improvement
or
or
or
or
worse.
D
How
many
good
should
there
be-
and
there
is
another
part
of
this
I-
think
this
doesn't
apply
to
the
hospital
sector,
but
it
does
apply
to
PMS
and
adult
social
care,
which
we
there
could
be
a
criticism
that
we've
defined
good
so
broadly
that
we
have
artificially
made
everywhere
good,
because
at
the
moment
the
the
the
good
good
and
outstanding
adult
social
care,
but
it's
mainly
good,
is
84%.
Eighty
four
percent
of
adults
solution
care
provision
is
beyond.
Is
it
that
good
or
outstanding
level
for
PMS
it's
95
percent?
D
So
now
that
sounds
sounds
a
little
bit
implausible
to
me.
That
everywhere
is
that
that
good
practice
is
Seward
and
I.
Don't
think
we're
we
it's
possible,
we're
not
helping
the
situation
of
improvement
by
drawing
the
the
line
that
the
parameters
of
goods
so
broadly
that
people
are
automatically
in
it
when
they
may
not
deserve
it
to
the
price.
D
But
you
know
the
tale
of
good
may
not
be
that
good
and
and
it's
quite
difficult
to
move
out
of
it
into
something
better
and
so
so.
I.
Take
your
point
that
everywhere,
being
good
or
better,
is
a
good
ambition,
and
but
we
just
need
to
make
sure
that
it
means
the
right
thing
and
it
means
something.
Consistent
and
I.
I
agree
with
you,
Ted.
H
The
quality
presumably
follows
the
normal
distribution,
so,
if
everywhere
is
good,
I
would
say
we
probably
set
set
out
our
expectations
wrong,
because
we're
trying
to
improve
and
I
think
it
comes
back
to
what
Lewis
was
saying
that
if
every
way
it's
good,
then
how
do
we
drive
improvement?
Well,
it
must
be
either
pushing
everywhere
to
outstanding
or
redefining
what
good
is
and
I
think.
H
A
M
Thanks
so
in
terms
of
what
we're
doing,
we
are
working
to
more
of
a
balanced
scorecard
approach,
so
we
we're
looking
to
bring
that
forward
for
next
month.
I
hope
and
what
we're
keen
to
get
to
is
analysis
rather
than
just
presenting
data,
so
we're
looking
at
different
models.
Those
things
like
standard
deviations,
SPC
charts
and
all
that
sort
of
thing
to
bring
together
a
much
clearer
picture
of
what
the
actual
issues
are
as
well
as
that
we're
looking
around.
M
Can
we
actually
start
to
measure
our
our
impact
and
outcomes
as
well,
so
actually,
rather
than
just
counting
numbers?
What
difference
does
that
make
so
there's
a
lot
of
work
going
on
and
there
we're
using
a
new
power
bi
tools
to
help
us
present
that
data
in
a
better
way
and
it's
much
more
interactive
to
enable
people
to
drill
down
into
the
information
if
they
want
to.
F
You
just
to
pick
up
on
the
previous
conversation,
I'm
I'm,
really
keen
that
we
start
to
do
some
work
to
understand
that
the
ratings
across
all
three
sectors
and
and
make
sure
that
we
are
consistent
in
how
we're
determining
good
and
outstanding
in
terms
of
improvement.
I
think
with
we
had
an
event
recently
with
it
outstanding
practices
and
I.
F
Think
one
of
the
key
messages
from
that
event
was
actually
their
relentless
focus
for
improvement
and
never
feeling
that
they
were
good
enough
and
I
think
that
we
need
to
somehow
continue
that
and
I
don't
think
getting
an
outstanding
rating
has
stopped
their
foot
on
the
pedal
in
terms
of
improvement,
in
fact,
actually
I
think
it
was
their
improvement
culture
that
has
given
them
that
landing
rating
and
I
guess
the
other
point
I
just
wanted
to
make
is
that
with
primary?
And
what
I'd
like
to
understand?
F
More
is
actually
the
changing
landscape
and
the
impact
that
that
is
having
on
the
ratings.
There's
no
doubt
that
it's
not
a
static
picture
in
terms
of
the
primary
care
landscape
in
general
practice
at
the
moment.
There's
a
lot
of
changes
that
are
happening
and
have
happened
over
the
last
few
years
and
they're
going
to
continue
to
happen
with
primary
care
at
scale
providers,
and
we
need
to
understand
that
and
the
impact
that
that's
having
on
the
ratings
as
well.
So
I
agree.
G
You
two
points:
firstly,
a
bit
like
Louis
I
feel
like
I've
enough
to
remind
people
with
things
that
we
did
quite
a
long
time
ago.
We
didn't
define
good
service
users
providers
define
good
when
we
brought
people
together
in
2014.
It
was
that
group
of
people
that
defined
what
good
looked
like
so
I
take
your
point
about
whether
whether
and
I
think
things
would
inevitably
move
on
in
people's
and
perception
of
what
could
look
like,
should
and
and
and
does
change,
but
just
be
really
clear
about
where
we've
got
to
with
all
of
these
sectors.
G
We've
defined
good
with
people
use
services
and
with
providers,
so
just
just
just
to
say
down,
because
that's
the
point
you
remember
it
I
think
also
to
say
the
national
stats
I
agree
with
you.
It
would
look
static.
It
absolutely
isn't.
It's
a
combination
of
organizations
changing
between
good
and
requires
improvements
and
I
think
the
really
interesting
part
of
that
is
when
you
begin
to
break
that
down
regionally
about
how
services
change
within
a
region
across
adult
social
care,
primary
care
and
hospitals
and
I.
Think
it's
useful
for
us
not
just
to
understand
it.
G
A
A
You
know,
17,000
inspections
is
a
lot
of
inspections
and
I
know
we
all
know
that,
but
it
really
sort
of
hits
you
when
you
look
at
it
over
the
air
and
I
think
it
is
worth
commending,
all
all
our
our
colleagues
for
being
able
to
deliver
17,000
infections
and
everything
that
goes
with
that
and
all
the
other
things
they
do.
So
that
was
that
was
sort
of
one
big
thought
and
the
other
big
thought
was
the
trajectory
on
pretty.
A
Do
think
it's
a
tremendous
achievement,
though
the
trajectory
really
is
now
moving
in
the
right
direction.
So
there's
were
sort
of
two
really
big
thoughts.
I
took
when
I
stood
back
from
the
detail
which
we've
been
discussing.
Is
there
anything
else
anybody
wants
to
raise
on
the
performance?
Otherwise,
can
we
just
note
the
performance
report?
Note
the
financial
position
subject
to
audit
and
know
the
various
action
plans
for
where,
where
we
are
trying
to
improve
performance,
sorry
Paul,
you
come
in.
N
They're
gonna
pour
cold
water
on
what
you
just
said,
but
I
think
it
is
worth
just
looking
at
that.
The
business
plan
priorities
as
well,
because
that
that's
quite
an
appointment
making
about
where
the
challenges
are
ahead
is
reflected
to
some
extent
within
the
risk
rate
over
the
rag
ratings
within
the
business
plan
priorities.
So
you
know,
you've
got
some
some
certain
things
in
there,
which
are
our
big
challenges.
I
had
particularly
around
the
the
delivering
of
the
digital
program
and
so
on,
and
that
that
that
slide
go
he's
off
business
plan.
N
A
A
A
A
P
Freaky,
chairman
Robin
Pike,
HealthWatch
hartfordshire,
patient
representative.
My
question
concerns
the
relations
between
CQC
and
the
Health
and
Safety
Executive,
and
my
attention
being
drawn
to
the
Memorandum
of
Understanding,
which
was
set
up
years
ago,
I
think
to
delineate
those
areas
where
there
could
be
an
overlap
and
the
considerations
that
would
decide
which
government
agency
would
deal
with
which,
when
it
came
to
enforcement.
P
Now
I'm
wondering
in
the
case
of
hospitals
who
decides
when,
for
example,
there
has
been
a
death
in
a
secure
psychiatric
unit
and
a
coroner
has
spoke
of
spoken
of
negligence.
Who
who
decides?
Who
will
make
the
enforcement
actions
because
it
might
appear
to
members
of
the
public
that
the
level
of
enforcement
opened
to
CQC?
A
So
I
mean
several
points
in
there.
Robinson
I
mean
first
of
all,
we
work
closely
with
with
HSE
and,
if
you
have
said
your
attention
being
drawn
to
the
MOU,
if
you've
looked
at
it,
you
will
see
there.
It's
all
clearly
set
out
who
who
does
what?
When
and
the
short
answer
to
your
your
question
is
that
the
we
CQC
lead
on
safety
and
quality
of
treatment
and
care
matters
involving
patients.
So
the
enforcement
for
those
issues
is
is
absolutely
with
us
and
that's
where
it
should
be.
A
Q
Yes,
so
just
to
build
on
what
you
were
saying,
Peter,
obviously
each
case
is
different.
I
think
what
does
mean
that
some
of
the
fines
that
you
see
in
cases
that
the
health
and
safety
have
have
led
goes
back
to
the
fact
that
there
are
particular
sentencing
guidelines
which
apply
to
those
health
and
safety
act.
Offenses
we
don't
prosecute
under
the
Health
and
Safety
Act.
We
have
a
different
set
offenses,
and
so
those
sentencing
guidelines
don't
apply
to
us
because
our
prosecution
powers
are
still
relatively
speaking
new.
Q
We
continue
to
build
our
own
case
law
and
each
cases
is
still
pretty
different.
I
think
the
courts
are
still
getting
familiar
with
our
offenses
and
powers,
so
it
may
be
that
some
point
in
the
future.
The
sentencing
guidelines
counsel
may
want
to
set
a
framework
for
CQC
offenses,
but
at
the
moment
we
don't
have
one
and
I
think
that
explains
some
of
the
differences
that
you
see.
Q
A
I
A
R
Name
is
Minnie
McCulloch,
James
and
I
have
to
say
that
mr.
Appleby
is
the
only
person
in
this
room
that
I've
heard
from
today
who
has
any
inkling
of
what
it's
like
to
be
a
family
member
who
has
a
relative
in
mental
health
care
unit?
My
brother
is
currently
detained
in
one
such
unit.
I
asked
for
the
assistance
of
the
Care
Quality
Commission
and
was
told
by
one
of
mr.
Baker's
staff
members,
Rebecca
Swan.
R
She
didn't
want
me
wasting
her
time,
because
the
CQC
does
not
engage
in
any
conversations
on
a
individual
level.
You'd
not
intervene
on
behalf
of
families
on
an
individual
level.
My
brother
at
the
moment
is
in
such
a
state
that
he
cannot
speak
in
sentences.
This
is
somebody
who
is
a
qualified
chef,
guitarist
composer,
and
at
this
moment
he
cannot
speak
in
full
sentences
and
the
CQC
miss
Rob,
miss
Rebecca
swallow
said:
don't
want
you
wasting
my
time.
R
We
then
asked
for
confirmation
from
the
hospital
can
they
show
proof
of
lawful
detention
of
my
older
brother,
mr.
Cozzi
Ranga
at
shoes
record
hospital
in
Surrey
told
us
that
we
were
not
entitled
as
a
family
to
see
the
documents
that
confirm
whether
or
not
my
brother
is
currently
normally
detained.
We
asked
the
irresponsible
clinician
dr.
Gerry.
Could
we
see
the
medical
charts
of
my
brother
and
he
said
he
would
call
security
and
have
me
removed
from
the
hospital.
We
then
asked
the
medical
director
of
the
hospital.
Could
we
attend
an
MDT?
R
R
We
will
not
be
disturbing
the
medical
professionals
to
have
a
discussion
with
you
and,
if
you
don't
stop,
we
will
have
a
meeting.
Just
haven't
noticed
on
your
brother
to
throw
him
out
of
the
hospital,
and
we
thought
great
do
that,
throw
him
out,
but
of
course
they
didn't
because
it's
a
private
hospital.
They
paid
the
last
amounts
of
money
by
the
NHS,
and
this
hospital
has
a
good
rating.
R
A
A
Come
to
the
end
of
the
line,
but
my
brother's
mental
health
is
deteriorating,
so
he's
retained
18
months
deteriorating,
so
I
am
quite
clear
that
we
have
a
process
for
dealing
with
your
complaint,
so
that
was
the
first
thing
I
wanted
to
say
and
that
that's
what
you
need
to
need
to
follow.
Secondly,
you
know
we,
we
have
our
roles
and
responsibilities
and
we
need
to
be
clear
about
what
we,
what
those
are
and
what
they
aren't.
So
when
somebody
says
we
can't
interfere
in
an
individual
case.
A
That
is
because
that
is
not
our
role
that
they
shouldn't
should
have
made
that
clear
to
you
and
then
I
think.
The
the
the
third
thing
I
wanted
to
say
is
that
you
know
I
mean
I
and
I'm
sure
everybody
in
the
room
were
extremely
sorry
to
hear
about
your
brother,
but
that-
and
we
do
need
that
information,
because
the
information
is
about
providers,
but
it
is
not
about
our
abilities
than
individual
case.
A
R
R
Because
at
the
moment
there
isn't
I
accept
what
you're
saying
that
you
don't
interfere
on
behalf
of
individuals
but
since
you're
all
sitting
here
discussing
what
a
fantastic
job
you're
doing,
you
need
to
hear
from
the
family
members
but
you're
not
doing
a
fantastic
job.
So
how?
What
is
it
that
you're
going
to
do
to
make
a
place
for
family
members
to
input
into
your
discussion
so
that
you
understand
really
what's
happening
on
the
ground?
That's
the
question
so.
A
I
want
anybody
else
that
reads
the
transcript
of
this
meeting
or
watches
it
that
getting
input
from
people
who
use
services
is
is
really
vital
to
the
work
of
the
CQC
and
the
last
thing
I
want
anybody
to
get
away
with.
Is
the
idea
that
that
we
aren't
interested
in
hearing
from
members.
It's
really
important
that
we
do
say
so.
I'm
sorry
about
your
situation,
I'm
sorry!
We
can't
discuss
it
further
today,
but
thank
you
for
coming.
There
was
a
lady
in
the
front
row.
I
think
you
wanted
to
ask
a
question.
S
S
S
S
S
S
Now?
Those
are
my
questions
and
now
my
little
supporting
statement,
it
seems
to
me
from
where
I
sit,
that
the
emphasis
on
record-keeping
and
maintenance
now
outstrips
the
primary
purpose
of
those
records,
improving
clients,
care
and
recognizing
excellence
or
identifying
shortcomings
at
the
point
of
delivery.
S
Thus,
the
content
of
document
documentation
that
has
to
be
filled
in
by
carers
and
I
have
seen
this
increase
since
the
last
since
the
very
recent
CQC
inspection
of
my
husband's
agency,
the
the
content
of
the
document
has
to
be
filled
in
by
carers.
Operating
on
strict
time-tables
is
now
excessive
and
takes
away
their
time
from
the
actual
care.
It
is
the
actual
reverse
of
the
person-centered
care
to
which
lip
service
is
paid
and
which
depends
on
genuine
client
carer
interaction
whose
content
and
this
my
point
may
not
be
prescribed
to
the
minutest
detail.
S
The
failure
to
see
a
wider
picture,
because
I
would
argue
of
the
emphasis
on
my
new
TI
as
it.
The
is
that
the
crux
of
what
I
see
is
the
CQC's.
Now
originally
I
was
going
to
say
inadequacy,
but
I've
met
you
all
now
and
I
know
you're
caring
and
you
want
to
do
this.
So
I
would
say
it's
a
slightly
wrong
trajectory.
S
If
an
agency
can
score
good,
when
care
has
failed
to
stay,
the
allotted
time
turn
up
hours
late
at
weekends,
so
that
a
morning
call
and
a
lunch
call
affectively
roll
into
one
have
no
traveling
time
between
calls
and
are
fined
if
they
drop
a
roster
for
such
as
things
such
as
childcare
emergency.
What
does
good
mean
in
that
context?
If
an
agency
scores
outstanding
after
one
of
its
carers
has
been
convicted
of
theft?
What
does
that
mean
and
I'm
not
saying
that
the
agency
would
have
known?
A
S
A
Going
to
then
say
is
that
I
think
there
are
so
many
points
in
what
you've
raised
and
they're
important
points
that
we
ought
to.
We
will
reply
to
you
in
writing.
I,
don't
think
we
can
do
it
justice
without
noticed
right
now,
but
I
think
there
is
one
point.
I
did
just
want
to
make
and
probably
perhaps
just
to
close
the
meeting
on
this,
but
it
goes
back
a
little
bit
to
the
previous
point.
A
You
know
we
really
do
want
information
from
people
like
you
and
we
do
take
very
seriously
the
information
that
we
get
so
I.
Don't
again
what
anybody
go
away
with
that
with
the
sense
that
the
information
from
people
who
are
either
themselves
service
users
or
are
relatives
of
or
friends
of
service
users
is
not
really
important
to
inform
the
way
we
go
about
our
work.
So
that's
a
regenerative
specifics
that
you've
raised.
We
will
come
back
to
you
in
writing.
So
Oh
David.
You
want
to
ask
questions.
T
The
other
point
Louis
said
was
suggested
that
in
the
strategy,
the
next
strategy
good
should
be
redefined
and,
as
I've
said
in
the
past,
there
are
quite
a
lot
of
cases,
two
of
which
have
been
mentioned
by
the
two
previous
speakers,
where
good
is
very
likely.
Miss
applied
I,
not
sure
whether
it
applies
to
all
the
directorate's.
My
examples
that
I
did
collect
a
couple
of
years
ago
were
mostly
about
adult
social
care
and,
of
course
there
has
been
some
of
you
may
beware.
T
The
petition
has
been
circulated
by
somebody
called
Tanya
Taylor,
whose
father
was
abused
in
a
care
home,
and
yet
the
CQC
had
said
that
it
was
good
I,
don't
know
how
long
before
that
the
inspection
had
taken
place
before
the
abuse
happened,
but
I
don't
think
that
you
would
really
feel
that
was
a
satisfactory
situation.
Of
course,
if
it
was
a
one-off,
you
could
say
well,
it
is
one-off,
but
it
does
seem
to
happen
quite
a
bit
and
I
wonder
if
it
isn't.
T
You
need
to
think
not
only
how
good
should
be
redefined,
but
also
about
the
questions
of
how
you
find
out
whether
a
place
is
really
good
or
not,
because
you
can't
really
just
walk
into
a
care
home
where
they
are
more
or
less
expecting
you
and
necessarily
see
the
kind
of
things
that
happen.
Two
o'clock
in
the
morning
when
the
night
staff
are
on
so
you
know,
I
do
recognize
the
CQC
wants
to
do
a
good
job
and
wants
to
stamp
out
abuse
and
neglect
I.
A
I
think
what
Louis
was
saying
is
right
and
I,
don't
think
Louis.
You
said
we
should
redefine
it.
We
used
to
think
you
said
that
we
should
be
thinking
about
whether
we
should
redefine
it
and
I.
Think
there's,
there's
there's
there's
a
lot
of
work,
we're
going
to
be
doing
to
lead
up
to
the
next
next
strategy.
Doesn't
you
know
that,
because
the
present
strategy
we've
still
got
to
deliver,
got
to
implement
the
president's
strategy
that
runs
until
2021?
After
that
we
would
have
a
new
strategy
the
next
couple
of
years.
A
We
need
to
be
thinking
about
lots
of
issues,
some
of
which
have
been
raised
by
the
board
this
morning,
some
of
which
you've
just
raised
and
other
issues
as
well,
so
I
think
it's
something
that
we
absolutely
need
to
be
thinking
about
and,
as
I
was
saying
at
the
end
of
our
discussion
about
the
performance
report
and
Paul
commented
on
this
as
well.
You
know
we
are
by
no
means
complacent.
A
I
do
think
that
this
organization
has
come
a
long
way
and
it's
doing
a
lot
of
good
stuff
and
the
trajectory
is
in
the
right
direction.
That
is
not
to
say
that
any
of
us
think
it's
perfect
and
we're
not
at
all
complacent,
so
I
think
we
will
go
on
working
out
how
we
can
get
better
at
what
we
do
on
a
continuous
basis.
Yeah.
You
wanted
to
say
something,
and
then
that
is
the
end
of
the
meeting.
Thank.
C
So
we
have,
in
our
board
performance
report
our
performance
around
how
we
deal
with
whistleblowers,
and
we
encourage
people
to
talk
to
us
about
what's
going
on
inside
and
inside
a
particular
setting,
because
quite
often
this
abuse
doesn't
go
go
on
on
its
own.
It's
not
a
single
individual.
Other
people
will
be
aware
of
it.
We
also,
as
Peter
said
a
couple
of
times.
C
Now
we
really
value
the
input
from
from
in
Virgil's,
who
are
perhaps
relatives
or
friends
of
people
who
are
being
cared
for,
and
if
they
see
something
that
that's
wrong,
then
we
get.
We
have.
We
get
many
thousands
of
calls.
Every
year
we
get
contacts
to
our
website
where
people
talk
to
us
about
their
experience
of
care,
and
then
we
feed
that
into
our
into
our
assessments
of
particular
institutions,
sometimes
that
triggers
an
immediate,
immediate
reaction
of
a
location.
C
Sometimes
it's
something
that
we
we
aggregate
with
other
pieces
of
information
and
that
may
bring
forward
an
inspection
and
so
forth
other
times
we
hold
on
to
it
until
we're
next
in
that
location.
So
it
is
really
important,
but
we
are
part
of
of
almost
a
triumvirate
of
people
that
the
employees
of
the
institution,
the
friends
and
relatives
as
well
as
us,
working
together
alongside
others
such
as
commissioners
and
so
on.