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From YouTube: CQC board meeting – January 2018
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A
Okay,
good
morning,
everybody
welcome
to
the
January
board.
Can
I
make
a
particular
welcome
to
our
two
new
board:
members,
Liz,
seis
and
and
John
ordem.
Really
welcome
good
to
have
you
on
board.
We
have
an
apology
from
Paul
Roux
who
is
ill
Paul.
If
you
happen
to
be
spending
your
sick
leave
watching
this
I
hope
I
hope
the
discussion
makes
you
feel
better
Arthur.
A
Are
there
any
declarations
of
interest
that
anybody
needs
to
to
make?
Okay?
That's
that's
good
minutes
of
our
meeting
of
the
19th
of
December.
Are
they
true
and
accurate
record
of
everything
we
discussed
excellent?
Thank
you.
They
are
therefore
approved.
Matters
are
rising
the
there's,
an
action
log
and.
A
B
B
First
thing
is
just
to
say
that
term
now,
with
the
11
o'clock,
the
news
of
the
announcement
of
the
appointments
of
Kirsty
Shaw
as
the
chief
operating
officer
for
CQC
will
will
go
out.
Kirsty
will
join
us
on
the
1st
of
March
I
understand
so
I
have
to
say
picture
and
I
did
the
appointment
together.
I
think
I
think
she
was
an
outstanding
candidate
and
I've
got
great
optimism
about
the
contribution
she'll
make.
B
So
this
is
taking
over
it's
substantially
the
role
that
Eileen
did,
but
slightly
tweaking
the
role
to
give
a
greater
focus
on
the
overall
performance
of
the
organisation
and
happening
that
so
I'm
really
pleased
to
be
able
to
make
that
announcement,
and
then
I
just
want
publicly
to
congratulate
angry
on
her
CBE
in
the
New
Year's,
Honours,
List,
I'm.
Sure
many
and
the
board
would
support
that
and
I
know
she
says:
Twitter
is
exploded,
I,
don't
quite
know
what
that
means
explode
far
enough.
As
far
as
I'm
concerned,
but.
B
B
D
You
so
just
to
look
at
the
performance
report
and
just
to
pull
out
three
items
for
you,
although
obviously
there
may
well
be
other
questions
that
you
would
want
to
ask.
The
first
is
on
registration
and
to
note
that
our
activity
continues
to
increase,
and
it's
slightly
slightly
awkwardly
worded
in
the
report,
but
hopefully
you
can
kind
of
see
the
sense
of
it,
which
is
that
from
each
quarter
throughout
this
year
we
have
seen
an
increase
in
activity,
and
that
obviously
puts
pressure
on
the
team
in
terms
of
hitting
the
timeliness
targets.
D
But
we
are
continuing
to
be
better
performing
than
last
year
in
our
timeliness,
targets
dipped
a
little
bit
in
November,
but
you
know
there
is
a
kind
of
a
rhythm
of
this
in
terms
of
how
it
goes
so.
I
would
like
to
kind
of
commend
the
team
for
their
continued
effort
to
improve
clearly
the
work
that
we
are
doing
around
the
processes
and
procedures
to
strip
out
some
of
the
bureaucracy
around
this,
which
will
help
to
speed
up
our
timeliness.
D
Also,
looking
at
the
work
that
we're
doing
with
the
digital
team
to
support
the
registration
team,
both
within
my
Directorate
but
obviously
the
very
important
bit
of
registration
that
happens
in
NCSC
as
well,
and
so
we
will
continue
to
see
kind
of
improvement
over
the
next
two
years,
but
just
wanted
to
draw
that
out
and
to
make
the
point
about
the
increased
activity.
The
second
area
is
in
adult
social
care
inspection
and
just
to
reflect
that
we
have
had
significant
turnover
and
vacancies
within
the
team
there
and
that
has
impacted
on
our
capacity.
D
But
what
was
also
impacted
on
our
capacity
to
go
to
these
services
that
we
said
that
we
would
go
to
within
certain
time
periods
has
been
prioritizing
risk.
So
we
are
returning
to
our
inadequate
sand,
requires
improvements
in
the
main
within
the
sixth
and
twelve
months
that
we
said
that
we
would,
but
unfortunately,
we're
not
getting
back
to
the
goods
and
outstandings
within
the
two
years
that
we
said
that
they
would,
in
all
cases
we
are
and
some
because
we
are
responding
to
the
risks
that
have
been
raised
with
us.
D
And
you
can
see
in
the
report
that
are
the
good
services
that
we
are
going
back
to
and
23
percent
of
them
are
deteriorating
20
percent
to
cries,
improvement
and
3%
to
inadequate,
and
that
is
on
slide
eight
and
that
obviously
puts
pressure
on
the
team
in
terms
of
we
weren't
expecting
that
level
of
deterioration
in
terms
of
the
activity
and
and
generally,
and
particularly
those
that
are
dropping
down
to
inadequate,
usually
means
that
there
is
enforcement
action.
That's
happening
there
as
well,
which
is
an
increase
of
activity
for
the
team.
D
We
are
monitoring
that
carefully
and
particularly
monitoring
how
long
it's
taking
us
to
get
outstanding
and
inadequate
reports
out,
which
is
where
there
is
obviously
a
significant
level
of
scrutiny,
and
sometimes
particularly
on
the
Atlantic
aside,
things
a
significant
level
of
challenge,
but
the
teams
are
receiving
weekly
reports
identifying
where
the
delays
are
where
the
outliers
are,
and
inspectors
and
inspection
managers
are
following
those
up
to
make
sure
that
we
do
that
as
quickly
as
possible.
So.
E
E
E
So,
in
other
words,
what
is
it
that
allows
a
trust
or
a
care
home
to
improve,
and
what
is
it
that
prevents
that
and
what
is
it
that
leads
to
a
deterioration
after
we've
made
a
rating
and
in
the
improvement
science
that
we're
trying
to
get
to,
and
we
may
have
better
data
than
more
or
less
any
anybody,
I
would
say
so
I'm
just
keen
that
we
use
that
I
have
a
couple
other
points,
but
I
can
hold
on
to
them.
Unless
you,
let's.
F
F
Go
first,
I
was
gonna,
highlight
that,
actually,
when
I
came
to
reporting
them
back
on
the
hospital's
performance,
because
there
is
a
continuing
trend
of
trust
ratings,
improving
as
you
say,
but
it
is
mix
and
some
are
getting
worse,
but
actually
the
majority
are
improving
and
that
is
encouraging
and
I.
Think,
first
of
all,
it's
a
great
tribute
to
hospitals
working
under
enormous
pressure
that
they
are
driving,
improvement
and
I.
F
Think
we
need
to
recognize
the
amount
of
work
that's
going
on
in
these
organizations
to
do
that
and
that
script
you
get
to
the
staff,
but
also
the
management's,
I,
think
the
factors
behind
it
were
reflected
in
our
report.
Last
July
driving
improvement
and
everything
we've
seen
since
has
confirmed
the
conclusions
of
that
report
that
this
is
about
leadership.
It
is
about
culture,
it
is
about
staff
engagement
and
it's
about
effective
governance
and
I.
Think
that
terms,
organizations
around
and
increasingly
we
are
seeing
organizations
learning
from
that
and
developing
their
own
quality
improvement.
F
Cultures
and
I've
been
to
several
organizations
recently
where
this
is
very
much
what's
driving
it,
and
those
are
the
organizations
that
are
really
changing
and
I
highlight
some.
Just
this.
Last
week
we
published
a
report
on
Royal
Berkshire
Hospital.
It
was
our
I
will
be
published
last
report
two
or
three
years
ago.
It
is
now
good
and
it
is
very
high
good.
The
Royal
Berkshire
Hospital
itself.
The
site
is
current
and
outstanding,
and
that
is
a
great
tribute
to
an
organization
working
under
pressure
to
the
virial
improvement.
F
D
Hopefully,
some
in
May
demonstrating
that
and
again
I
think
that
very
similar
issues
will
come
come
out
at
the
to
what
we
saw
in
hospital
trusts,
but
it'll
be
interesting
to
see
if
there
are
any
variations
or
any
kind
of
nuances
from
an
adult
social
care
perspective.
So
we
are
doing
that
work
to
mine
into
that
data
and
also
to
do
it
on
the
basis
of
conversations
with
the
organization's
themselves.
D
So
the
registered
managers,
their
teams
and
people
who
are
using
services
to
to
find
out
what's
happened
there
so
we'll
be
able
to
do
something
similar
to
what
Ted's
team
did
last
year.
The
second
thing
on
deterioration
I
do
think
that
two
things
one
there
probably
is
more
work
that
we
can
do
I
mean
I,
think
we
are
sitting
on
an
innate
and
amazing
evidence
base
of
what
are
the
factors
that
kind
of
caused
that
and
new.
There
are
conversations
that
were
having
with
Malta's
team.
D
Think
that
it's
those
factors
which,
if
we
didn't
kind
of
get
into
a
much
more
thorough
analysis
of
it,
we
would
be
seeing
and
and
I
think
it
is
important
for
us
to
use
that
information
to
highlight
what
people
need
to
be
aware
of.
But
what?
What
also
ourselves
and
the
rest
of
the
system
needs
to
be
aware
of
in
terms
of
the
things
that
we
need
to
do
to
improve
Steve.
G
Rated
doesn't
include
the
majority
of
our
locations,
which
actually
are
in
in
dentistry
by
volume
because
they're
not
rated
after
GP
ones.
This
data
I
think
is
as
accurate
as
we
can
get
it.
Apart
from
the
fact,
there
are
a
number
of
surgeries
which
cease
to
trade
or
merge
or
are
taken
over,
so
these
are
based
on
going
back
to
locations
we've
already
been
to.
G
What
we
need
to
do
is
some
more
work
to
give
you
the
figures
on
the
Takeovers,
mergers,
etc,
and
it
is
quite
fluid
and
we
are
finding
some
deterioration
in
some
areas
more
than
others,
so
I
think
there's
a
richness
in
the
data.
The
numbers
are
still
quite
small,
but,
as
the
summer
goes
on,
we'll
have
something
quite
interesting
to
look
at
I
mean
so.
B
Improvement
have
got
better,
which
was
a
subject
to
the
public
Cashin.
But
what
is
the
challenge
of
holding
that
level
of
performance
and
that
level,
rather
than
deteriorating
and
I
think
this
plays
the
risk
register
conversation
we
had
earlier
this
morning
and
I
think
it's
behind
Roberts
question
for
me
about
what
is
the
oversight
of
these
services?
B
The
challenge
I
think
for
us
is
because
of
the
risk
bears
were
going
back
to
those
services
were
the
most
worried
about
to
the
minute
and
therefore
it
is
almost
you'd
be
better
at
this
than
I
am
by
a
long
way.
There'll
be
an
inevitability
that
if
you're
going
back
to
those
that
you're
most
worried
about,
you
are
going
to
find
something.
B
But
I
think
it
is
something
we
need
to
continue
to
keep
under
under
quite
close
scrutiny
to
try
and
understand.
We
did
say
it
in
a
quite
a
transparent
way.
I
thought
on
the
state
of
care
report
in
October
and
I'm,
not
sure
it
got
picked
up,
I
think
there's
a
particularly
dominant
narrative
running
at
the
minutes
about
services,
the
NHS
in
particular,
about
money
and
actually
there's
something
I
think
which
is
quite
important.
B
What
do
we
understand
and
I
for
one
wouldn't
like
so
actually
give
it
to
finish
tip
you
about
why
things
are
deteriorate,
but
I
think
we
do
need
to
understand
that,
and
that
comes
on
to
the
predictive
stuff
that
we
were
talking
about
earlier,
that
you
were,
you
were
raising
the
pitch
of
sorts
bouts
as
well,
so
I
think
it's
a
really
important
question.
So
listen.
H
I
Thanks
very
much
I
wanted
to
ask
about
the
in
the
report
that
this
comment
that
warning
notices
are
going
down
and
criminal
actions
are
increasing
and
I.
Suppose
I
wanted
to
understand.
Is
this
a
shift
in
our
own
policy
in
terms
of
how
we're
using
the
powers
at
our
disposal
and
or
is
it
that
there's
a
change
in
the
numbers
of
providers
who
are
meeting
a
threshold
for
criminal
interventions
and
and
what
the
implications
of
whichever
of
those
are
for
her
impacts
of
use
of
these?
In
this
way,.
B
I,
don't
think
it's
either/or
I
think
it's
and,
and
so
we
are
using
the
criminal
powers,
power
to
prosecute
and
Criminal
Investigations,
more
and
I
think
we
are
reflecting
on
what
is
the
impact
of
a
warning
notice?
What's
the
change
we're
trying
to
get
from
issuing
a
warning
notice
and
using
those
in
a
much
more
strategic
and
judicious
way?
So
it's
a
bit
of
both
to
be
honest
list.
D
That's
that's
right,
and
and
also
on
the
criminal
side
of
things.
It's
not
just
the
kind
of
prosecutions.
It's
also
use
of
fixed
penalty
notices
for
failure
to
display
ratings
and
failure
to
have
a
registered
manager
in
post.
You
know
without
kind
of
a
sensible
and
good
explanation
because,
as
we
know,
that's
absolutely
critical
in
terms
of
the
quality
of
care.
So
there's
a
variety
of
things
that
are
covered
in
the
criminal
prosecution
area
and
Dave
is
absolutely
right.
D
What
were
wanting
to
do
is
to
make
sure
that
we
are
using
the
most
appropriate
of
our
enforcement
toolkit
to
enforce
the
improvement
that
we
want
to
see,
or
indeed
to
it,
to
hold
providers
to
account
for
the
poor
practice
that
we
have
seen
and
and
I
think
that
we're
also
getting
better.
To
be
perfectly
honest,
we're
also
getting
better
at
recording
and
that
information
and
presenting
that
back
to
the
to
the
board
and
to
the
executive
team
as
well.
Robert.
J
Just
to
follow
on
ready
from
Steve's
point
about
figures,
concealed
closes
and
reconfigurations,
and
so
on
and
I
wonder
whether
this
would
it
would
be
helpful,
not
necessarily
all
the
time,
but
we
probably
have
access
to
what
the
figures
are
for
an
area,
because
if
you
one
GP
practice
closes,
there
will
be
enough.
The
patients
will
have
gone
somewhere
else
and
actually,
what
is
the
effect
of
our
inspections
and
our
general
activity
on
the
general
standards
of
an
but
as
measured
by
the
cumulative
numbers
of
good.
That
mean
definitely
inadequate
and
requires
improvement.
J
Now,
it's
not
as
simple
as
I
understand
as
counting
up
institutions
because
for
organizations,
because
it's
more
question
of
how
many
patients
we
exposed
them,
but
I.
Just
wonder
whether
we
worthwhile
considering
we
do
that
sporadically
in
terms
of
systems,
reviews
or
whatever
whether
it
would
be
something
we
could
look
at.
G
Interesting
when
you
look
at
London
compared
with
some
other
areas
and
also
in
general
medical
practice,
if
you
look
at
the
press,
there
are
some
areas
of
the
country
where
the
GPS
are
saying.
They're
stopped
we're
stopping
taking
additional
patients
on
because
of
the
pressure
and
because,
if
we've
got
a
practice
in
that
area,
which
is
failing,
we
then
have
to
balance
our
enforcement
activity
to
close
a
practice
or
to
suspend
the
practice,
even
if
they're
really
really
bad
in
an
area
where
the
system
is
so
stretched
and
there
aren't
any
other
providers.
G
G
E
Well,
the
other
was
a
comment
in
a
way
that
the
about
the
presentation
of
the
data
just
but
it's
on
the
same
issue,
and
it
would
be
useful
to
see
two
refinements
of
the
the
data.
What
one
is
it
would
be
useful
to
see
the
mental
health
contribution
here
separately
from
the
hospitals
as
better
as
a
whole,
because,
as
we
were
hearing
yesterday,
there
was
a
mental
health
story
reviewing
that
rgc
yesterday
and
that
you
see
the
mental
health
Trusts
listed
separately
on
improvement
in
ratings
and
so
on.
E
This
and
the
same
thing
applies
to
the
special
measures
data
we've.
We
used
to
say
where
the
where
special
measures
were
being
applied,
which
sectors
and
of
course
there
was
a
story
there
about
the
large
number
of
social
care
providers
and,
to
some
extent,
primary
care.
Actually,
there
were
almost
all
the
special
measures
locations
were,
and
we
don't
have
that
anymore.
We
have
a
kind
of
flow
diagram
now
which
tells
us
who
who's
coming
in
and
out
of
special
measures,
but
it
doesn't
tell
us
anymore
where
they
are
in
terms
of
their
sector
and
I.
E
Think
that
was
quite
a
useful
story
and
that's
one
I've
got
one
other
thing
which
is
about
safeguarding
data,
and
this
is
the
you
know
which
slides
this
it's
on
page
five
and
it's
about
safeguarding
and
I.
Think
it's
the
mandatory
actions
and
notifications
for
local
authorities,
if
I've
understood
correctly.
So
it's
slide
B.
E
We're
reporting
that
as
being
below
cape
our
KPI
on
this
every
month
and
how
our
performance
generally
doesn't.
Look
too
bad
because
it's
around
about
ninety
percent,
but
it
is
consistently
below
our
KPI
and
I.
Just
wondered
whether
that's
something
we
should
be
considering
more.
Where
there's
a
reason
for
that,
and
could
be
doing
more
about
that.
K
B
There's
a
bit
of
technical
detail
about
this
Lewis
I
can't
quite
retrieve
if
I'm
being
truthful
but
I.
Think
what
you
see
here
is
some
improvement,
but
I'd
want
to
combat
you
to
be
honest,
so
I
don't
feel
I'm
sufficiently
up-to-date
on.
Oh
because
if
you
look
at
the
other
stuff,
that's
going
on
in
ncsc
they've
made
really
good
progress
on
their
improvements
and
I.
B
L
It's
simply
that
it's
a
it's
a
it's
a
cumulative
figure,
so
it's
a
cumulative
figure
because
they
had
difficulty
when
they
were
setting
in
the
system
earlier
in
the
year.
So
it
was
quite
low,
so
they're
constantly
playing
catch-up,
but
they
are
actually
achieving
the
target
on
a
month-by-month
basis.
Now
and
that's
what.
C
The
second
thing
that
we've
done
because
we've
as
well
as
the
NCSC
data
we've
had
consistent
performance
issues
at
making
that
last
8
to
10
percent
right
across
the
organization.
So
the
safeguarding
committee
has
done
a
sort
of
end-to-end
review
of
the
process
trying
to
work
out
whether
there
are
process
improvements
we
can
make
and
what
we
particularly
discovered.
Is
it
two
or
three
steps?
There
was
a
huge
amount
of
duplication
with
double-entry
going
on
between
those
things.
C
That's
regenerating
safeguarding
alerts
and
those
things
that
were
also
generating
notifications
and
concerns,
and
we
agreed
at
the
last
safeguarding
committee
to
strip
that
duplication
out
and
create
a
much
more
streamlined
process,
and
we
believe
that
that
will
make
a
big
difference,
because
it
will
mean
two
things.
One
is:
is
that,
particularly
in
some
of
the
high
referral
areas,
particularly
adult
social
care,
it
will
make
a
difference
to
the
numbers
of
alerts
and
concerns
that
inspectors
are
needing
to
deal
with
on
a
daily
basis.
C
But
more
importantly,
it
will
increase
the
sense
and
their
confidence
that,
if
it
comes
through
with
a
safeguarding
a
lot
of
concern,
it
is
there
is
something
that
needs
to
be
done
with
it.
At
the
moment,
it's
generated
quite
a
lot
of
false
negatives
and,
if
we're
quite
honest
and
on
a
priority
day,
a
sense
from
inspectors
that
there
probably
won't
be
anything
there
and
therefore
they
leave
it.
So
the
change
of
this
will
be
to
enable
that
focus.
C
A
B
H
I
do
thank
you.
Thank
you.
Peter
I
mean
to
left
the
old
question,
but
it's
something
like
this
playing
on
my
mind
as
I.
Listen
to
the
conversation
we're
talking
about
the
ratings,
really
a
lot
of
the
that
the
rating
changes
to
say
requires
improvement
or
inadequate.
I
down
to
stuff
and
stuff
numbers
and
resourcing
and
in
finding
rough
I
had
to
quit
stuff,
particularly
that
little
social
care
and
potential
Kristen.
We
also
talked
about
sort
of
predictive
and
how
to
predict
these
things.
H
The
left-field
question
is
really
one
thing
that
we
know
is
about
to
happen
is
brexit
and
that's
gonna
have
a
huge
impact
on
potentially
depending
on
the
type
of
breaks
that
we
have,
and
we
know
it's
going
to
happen
now.
Just
my
question
was
really:
is
there
any
way
of
doing
any
form
of
impact
analysis
on
what
the
the
effects
on
I'd
also
show
care
in
particular,
but
potentially
trusts
as
well?
D
Two
or
three
things
on
that
one
you're,
absolutely
right.
The
we
are
already
seeing
the
impact
of
breakfast
on
staffing,
both
in
terms
of
the
numbers
of
nursing
staff
from
European
countries
coming
on
to
the
register
and
those
that
are
leaving
and
also
available,
'ti
of
staff
in
adult
social
care
at
all
the
grades
and
the
it's
an
it's
an
issue
for
the
Health
Service
and
it's
a
big
issue
for
a
lot
social
care.
There's
actually
twice
as
many
people
working
in
adult
social
care
from
European
Union
as
there
is
in
the
Health
Service.
F
F
The
next
phase,
as
I
say,
is
well
embedded,
but
we
are
not
complacent
and
I
think
we
are
endeavoring
to
learn
and
improve
it
and
we're
building
quality
improvement
methodology
into
the
next
phase
going
forward,
because
we
see
this
is
something
not
just
that
we
do
once
and
get
right,
but
something
we
continuously
improve
and
that
is
going
to
feed
into
our
ability
to
approach
data
in
a
different
way
and
drive
drive
efficiency
improvements
going
forward
for
the
for
the
inspectors.
The
reports
are
now
being
published.
F
We've
been
publishing
our
annex
phase
reports
and
we've
already
discussed
some
of
the
changes
that
we've
seen
in
the
ratings,
and
they
those
changes
have
continued
in
on
the
next
phase
report,
so
demonstrating
that
we
can
demonstrate
changes
in
quality
on
the
next
phase,
as
we
were
on
the
previous
comprehensive
inspections
we
mentioned
earlier
on
about
the
number
of
trusts
going
from
RIT
good,
which
is
really
encouraging.
But
I
should
stress
that
there
are
a
significant
number
of
trusts
about
an
equal
number
who
are
requires
improvement
in
our
staying
requires.
F
Improvement
on
re-inspection
now
requires
improvement.
To
some
extent
was
if
you
like,
the
majority
of
crusts
and
the
first
round
of
inspections,
and
we
are
worried
that
some
trusts
are
seeing
that
as
a
kind
of
comfortable
place
to
be
and
trusts
have
demonstrated
that
even
in
the
present
environment,
they
can
significantly
improve
their
services
and
that's
what
we're
expecting
to
see
in
all
trusts.
So
we
are
thinking
through
our
approach
to
the
trust
at
our
present.
F
Stagette
requires
improvement,
which
we
don't
think
is
such
a
stretch,
a
place
for
them
to
be,
for
those
that
deteriorate
to
inadequate,
of
course,
when
there's
a
special
measures
regime-
and
that
is
I,
think
being
very
effective
in
turning
trust
around
it
takes
a
while,
but
trusts
are
turning
around
and
we
took
the
lady's
trust
out
of
special
measures.
Only
a
week
ago,
there
are
now
15,
plus
till
these
special
measures,
and
many
of
them
are
making
progress
in
I
hope.
F
During
this
next
few
months
there
we
will
be
able
to
recommend
further
trust,
came
after
special
measures
going
forward
into
in
terms
of
performance
going
back
to
the
performance
issues.
Again,
it's
important
to
stress
that
we're
doing
a
lot
of
work
on
report
timeliness
that
is
still
a
concern
for
us
in
hospitals.
The
next
phase
has
been
designed
around
very
tight
timescales
and
are
very
grateful
to
our
staff
who
are
working
to
those
and
we
are
delivering
the
next
phase
reports
in
a
timely
manner.
F
We
still
have
in
independent
health
provider
reports
that
we
are
clearing
a
backlog
off,
so
we
haven't
quite
hit
the
the
KPIs
yet
and
but
a
lot
of
work
is
going
on
and
the
average
time
to
projections
reports
is
coming
down,
so
I
hope
we'll
be
able
to
demonstrate
that
we
are
achieving
the
KPIs
in
the
very
near
future.
Thanks.
G
You
Jerry
I've
got
a
couple
of
issues.
One
of
them
was
safeguarding,
but
mercifully
is
one
of
my
deputies
answered
all
of
the
she
anticipates
things
really
well,
so
that's
excellent,
but
we
there
are
systems
issues
both
in
safeguarding
and
in
how
we
look
at
the
full
quarter
breaches
which
our
new
director
of
business
manager
is
taking
as
priority,
and
they
involve
the
whole
system
through
data
input
as
well.
I,
don't
want
to,
as
Ted
said,
very
well
for
his
staff,
congratulate
our
staff
again
for
the
continuing
good
progress
towards
publishing
reports
very
quickly.
G
It's
something
that's
come
up
over
the
last
few
years
for
the
hold
of
CQC,
National,
Audit,
Office
and
health.
Select
committees
and
performance
is
very
good
on
that
now
and
it's
pleasing
to
be
able
to
say
that
at
the
same
time,
as
the
staff
survey
for
primary
care
is
excellent,
that
we
can
do
even
better,
but
it
is
a
really
really
good
response
from
her
from
our
staff.
G
K
John.
Thank
you,
a
question
for
Ted
there's
a
lot
of
reports
this
morning
about
younger
nurses,
leaving
the
system
and
I
wondered
if
that
was
correlated
at
all
in
the
sort
of
ratings
and
your
inspections
and
real
and
secondly,
going
back
to
the
brexit
point.
There's
a
90
percent
drop
in
application
from
EU
nurses
to
come
and
work
here
and
those
two
things
seem
tricky.
I
wondered
what
your
prediction
might
be
going
forward.
K
F
Workforce
is
one
of
the
key
pressures
facing
the
NHS
at
the
moment,
its
workforce
across
all
groups,
but
clearly
nurses
are
the
most
common
of
the
of
the
largest
part
of
the
workforce
and
so
there's
a
particular
concern
in
that
regard.
I
think
when
we
started
our
comprehensive
inspection
regime
several
years
ago.
There
were
real
concerns
about
the
the
plans
for
staffing
clinical
areas
and
we
had
to
challenge
those
but
trusts
I
think
have
stepped
up
to
that
and
I'm
recognizing
the
staffing
they
need,
but
they
still
have
problems
in
recruiting
staffing
and
I.
F
Think
is
a
major
challenge
for
trust,
going
forward
and
they're
very
few
trusts
we
go
to
who
don't
tell
us
that
nurse
recruitment
is
a
real
issue
for
them,
a
lot
of
the
time,
they're
filling
gaps
with
agency
and
temporary
staff,
which
who
may
be
very
good
staff,
but
inevitably
because
they
are
not
permanent
staff.
They
don't
have
that
same
continuity
of
care
that
permits
they'll
provide.
F
Occasionally
we
see
trusts
that
have
difficulty
filling
ships
and
those
are
trusts
where
we
sometimes
have
to
take
action
over
their
staffing
numbers,
but
but
they
are
working
very
hard
to
do
that
in
terms
of
going
forward.
I
think
one
of
my
chief
concerns
is,
and
if
you
read
some
of
the
stories
about
the
young
nurses
that
you're
talking
about
this
morning,
they
they
talk
about
the
pressures
they
work
under
and
they
talk
about
the
difficulties
they
work
under
and
I
think
it
is
very
important
that
we
focus
on
the
support
and
well-being
of
staff.
F
They
are
working
under
pressure
and
we
need
to
recognize
that
actually,
the
staff
needs
support
if
they're
going
to
provide
excellent
care
to
their
patients.
I
am
still
worried
about
the
NHS
staff
survey.
That
still
remains-
and
it's
been
stuck
in-
that
way
for
many
years
with
a
high
level
of
staff
reporting
bullying
at
work.
You
know
and
I
think
that
is
a
real
concern
in
other
services.
I
think
would
be,
it
would
be
questioned.
So
I
think
when
we
look
at
staffing.
F
Some
of
it
is
about
recruitment
and
the
issues
around
brexit
and
other
staff.
Recruitment,
I,
think,
is
a
question
that
part
of
it
is
about
retention
and
actually
making
staff
enjoy
and
get
satisfaction
from
their
work.
It
is
a
great
vocation
working
in
the
health
service
and
the
greatest
satisfaction
you
get
is
from
that
one-to-one
interaction
with
patients
and
feeling
you're
making
different
to
individual
people's
lives.
F
J
My
question
is
what
the
I
mean
a
fair
amount
of
frankly,
not
entirely
coordinated.
Work
is
going
on
around
the
system
about
how
we
should
improve
recruitment
retention,
the
experience
of
quality
of
life
for
staff,
but
I
wondering
what
contribution
kept
the
Care
Quality
Commission
to
make
to
that
work,
in
particular,
by
a
way
of
identifying
the
good
practice
that
undoubtedly
exists
in
some
trusts.
We
don't
have
quite
as
much
of
a
problem
as
other
places
to
do
those
things
which
actually
make
life
tolerable
and
he
possibly
even
value
for
for
staff.
J
Students
I
learn
who
have
to
pay
for
car
parking
spaces
where
they
go
to
remote
sites
and
don't
actually
get
any
reimbursement
in
relation
to
that.
All
these
sort
of
little
thing
they
sound
little
in
terms
of
money,
but
they
actually
extremely
important.
The
people
who
work
in
the
system
and
unless
something
is
done
about
this
I'm
persuaded
that
things
are
only
going
to
get
worse.
Leaving
aside
the
huge
challenges
of
brexit
immigration
control
policies,
and
so
on,.
F
Well,
I
would
support
that.
You
said
there
Francis
B,
it
is
making
staff
feel
valued,
but
also
make
giving
them
support
and
actually
doing
their
job
recognizing
the
difficulties
of
their
job.
So
some
of
it
is
some
of
those.
If
you
like,
peripheral
things,
I've
actually
make
their
love
working
lives
easier,
but
it's
also
the
culture
in
which
they
work
and
we've
seen
many
trusts
where
there
is
still
a
blame
culture.
If
things
go
wrong,
the
frontline
staff
get
blamed
well.
F
Clearly,
that
is
a
difficult
environment
at
which
to
work
and
staff
need
to
be,
if
you
like,
drawn
into
into
a
culture
where
they
feel
positive
and
supported
and
encouraged
to
do,
do
good
work.
If
you
look
at
our
outstanding
hospitals,
those
with
really
embedded
quality
improvement,
cultures
you'll
find
the
staff
there,
the
staff
recruitment
issues,
there
are
much
less
I'm,
not
saying
they
don't
face
challenges,
because
the
whole
system
faces
challenges,
but
there's
one
of
those
hospitals.
F
F
B
B
In
light
of
the
pressure
that
hospitals
are
on
the
in
respect
of
no
Nora
virus
and
influenza,
a
fur
trust
had
been
rated,
requires,
improvement
or
inadequate
or
had
been
a
concern
that
had
been
referred
to.
As
that
we
were
equally
concerned
about
and
we
were
intending
to
bring
forward
an
inspection.
Those
inspections
would
continue.
So
this
wasn't
a
moratorium
or
a
pause
on
inspections.
It
was
an
attempt
to
apply
a
risk
stratification
to
the
activity
that
we
were
going
to
undertake.
B
That
was
a
conversation
to
go
to
mr.
Ward's.
First
question:
who
made
the
decision?
That
was
a
conversation
that
we
began
on
Monday
a
couple
of
weeks
ago,
and
we
worked
at
that
through
the
executive
team
on
Monday
and
Tuesday.
We
checked
the
date,
so
we
looked
how
many
inspections
it
is
less
than
a
handful
of
trust
inspections
said
we'll
give
you
a
number
I
think
that
I
think
it's
less
than
five
and
we
published
that
decision
in
a
letter
that
I
signed
on
the
Thursday
of
that
week.
B
So
over
a
four-day
period,
we
actually
had
the
discussion
and
we
looked
at
the
pros
and
the
cons
we
looked
at
how
many
inspections
this
would
affect
on
the
inspection
program
until
the
decision
effectively
it
was
an
executive
team
decision.
I
take
responsibility
for
that.
It
was
my
name
that
went
on
the
letter.
I
stand
by
the
judgment
that
we
made
in
relation
to
this
in
relation
to
PMS
one
of
the
interesting
phenomena
that
I
think
we've
had
and
Steve
my
comments
on
this
as
well
Peter.
B
It
was
that
you
know
we
have
specialist
advisors
on
our
inspections.
These
are
GPS
he's
a
serving
GPS
and
a
number
of
GP
said
they
couldn't
do
the
inspection
which
was
programmed
here
in
January
because
of
the
level
of
flu,
and
they
couldn't
afford
to
be
away
from
their
surgery
and
get
recovering
because
of
they've
got
pressure
that
they'd
got
back
in
their
practices
that
it
needed
to
be
so.
B
In
a
sense,
we
were
trying
to
balance
the
impact
that
inspections
have
on
the
places
we
go
to,
but
we're
also
cognizant
of
and
sensitive
to,
the
fact
that
some
of
the
people
we
needed
wouldn't
be
released
from
their
inspections
to
do
some
of
this
stuff.
So
we
were
trying
to
ease
that
pressure
as
well,
because
we
did
need
specialist
advisers
on
those
inspections.
We
were
gonna
go
back
to
do
because
they
were
requires
improvement.
Ori
now
they
caught.
B
We
were
not
stepping
back
from
doing
those
inspections,
so
it's
a
balance
between
impacts
on
the
services
we
were
regulating
and
also
the
supply
of
particularly
specialist
inspectors.
We've
got,
we
are
sickness
rates,
haven't
done
inordinate
lehigh
within
CQC.
We
do
have
some
sickness
rate,
but
we're
not
inordinately
high.
So
so
they
influence
the
decision
in
terms
of
external
influences.
On
that
decision,
I
think
is
one
of
your
questions.
Mr.
ward,
there
were
no
external
decisions
whatsoever.
I
got
up
on
Saturday
morning.
B
B
Had
the
heads
of
inspection
coming
in
to
see
him
on
the
Monday,
it
was
an
opportunity
to
second
absolutely
bang
up
to
their
position
from
the
heads
of
inspection,
Steve
sport
to
the
DCIS
and
heads
of
inspection
during
Monday
and
Tuesday
Andrea
went
away
and
talked
to
her
people
her
management.
So
this
was
an
informed
position
that
we
took
Peter
and
I.
Think
your
third
question
mr.
Ward,
which
was
why
was
the
decision?
B
We've
got
to
remember
a
significant
number
of
our
hospital
and
GP
inspections,
in
particular
specialist
advisors,
a
crucial
part
of
that
team
that
goes
into
a
hospital
and
if
they're
serving
practitioners,
which
is
the
position
we've
been
trying
to
move
to
not
time
expired,
retired
practitioners
and
that's
an
issue
about
credibility.
Then
there
is
going
to
be
a
pull
on
their
time
about
are
their
presence
in
the
delivery
of
service
or
are
their
presence
on
inspections.
B
Where
we
did
do
some
scaling
back.
In
light
of
that
and
again
they
were
marginal.
They
were
very
small
numbers,
but
we
did
try
and
make
some
accommodations
to
it.
I,
don't
know
what
the
non-executive
colleagues
are
going
to
say
in
relation
to
this,
but
one
of
the
learning
points
from
their
C's
should
we
adjust
our
inspection
programs
over
the
winter
period
to
allow
for
the
workforce
supply
issue.
B
The
skill
supply
issue
that
we
in
acknowledgment
because,
as
Ted
has
said
to
us
on
many
occasions,
winter
comes
around
every
year
and
it
comes
for
us
as
well.
So
there
is
an
issue
about
how
we
just
provide
accommodation
to
this,
but
I
was
continuing
to
provide
assurance,
so
I've
gone
on
a
bit
more
pizza,
just
one
suspect
mr.
Ward's
question,
because
he
asks
three
questions
about
who
made
the
decision.
Was
there
any
influence
on
it
and
who,
and
why
did
we
do
it
so
I
hope.
B
A
Just
just
before
we
open
it
up
can
I
can
I
just
say:
David
I
mean
you
you.
You
rightly
said
this
was
a
decision
taken
by
the
executive
team,
but
I
reassure
the
board
that
I
was
fully
aware
of
it,
I
mean
so
it
was,
as
you
always
do,
keep
me
fully
informed
and
I
fully
support
it
Ted
just
again
before
we
open
it
up,
they
would
be
quite
hopeful
if
you
just
talk
about
the
role
of
the
the
relationship
managers.
F
We
are
not
standing
back
for
inspecting
services
under
pressure
if
we
believe
there
is
risk
to
safety
and
quality
for
patients.
Indeed,
we
will
probably
be
inspecting
in
January
just
as
much
as
we're
going
to.
We
may
be
inspecting
in
different
areas,
focusing
on
different
things,
depending
on
the
risks
we
identify
and
we
have
been
inspecting
emergency
developments
under
pressure
over
the
last
10
days
or
so.
We've
issued
enforcement
action
against
these
two
services
in
the
last
in
last
week
or
so
because
of
concerns,
and
we
will
go
on
focused
on
services
under
pressure.
F
We
want
to
be
supportive
and
I
think
it's
very
important
to
recognize.
The
staff
and
the
frontline
are
doing
a
great
job
in
delivering
care.
They
are
working
under
pressure.
They've
been
put
in
a
position
where
they
have
a
a
lot
of
work
can
begin
with
the
extra
flu
and
norovirus
etceteras,
as
david
has
mentioned,
and
they
have
great
difficulty
in
fronting
beds
for
patients,
and
so
they
are
working
under
enormous
pressure.
We
want
to
support
them.
F
They're
working
under
pressure
and
I
think
the
planning
has
gone
into
winter
has
been
highly
effective
in
making
sure
they
help
maintaining,
there's
good
quality
care
as
they
could.
You
will
remember
that
we
wrote
to
chief
executives
in
September
to
tell
them
what
we
thought
were
the
essential
elements
of
safety
built
on
what
we'd
learned
from
the
good
and
outstanding
any
departments
in
the
country
and
I
think
those
those
factors
are
being
taken
into
account
on
the
ground
and
we
will
ensure,
where
they're
not
being
taken
into
account.
We
take
action.
G
Stephen,
thank
you,
Jeff,
the
just
to
build
on
on
David
and
Ted's
points.
I
mean
we
were
having
a
debate
within
our
team.
At
the
same
time,
David
was
having
his
Saturday
morning,
coffee
and
reading
the
papers,
and
so
actually
we
came
in
on
Monday
morning.
Okay,
we
have
a.
We
had
a.
We
came
wanting
to
have
this
discussion
as
a
team
as
well
and
I
just
wanted
to
slightly
redress
the
balance
of
reporting,
in
that,
when
you
read
the
papers,
it's
all
about
hospitals,
it's
all
about
A&E.
G
G
We
were
having
some
issues
around
spars
having
to
cancel
inspections
and
short
notice
because
of
either
illness
or,
as
David
quite
rightly
said,
were
wanting
to
provide
care
for
their
patients,
and
so
we
were
reviewing
what
was
was
happening
and
for
us
it
was
an
important
decision
in
order
to
focus
the
resource
we
had
on
those
practices
we
were
worried
about
and
for
this
effects
now
101
practices.
G
We
have
postponed
the
inspections
of
none
of
those
were
acutely
worried
about
from
a
risk
point
of
view,
but
we've
reallocated
spars
to
focus
on
those
we
are.
Thirty
of
those
practices
have
been
rescheduled
already
and
we're
pushing
70
one
of
the
good
outstanding
practice
reviews
back
to
next
year.
Two
quarter,
one
because
we're
not
worried
it
was
just
part
of
our
ongoing
program.
G
The
feedback
has
been
really
supportive,
but
again
with
Ted
and
David
saying
as
well.
We
are
not
doing
this
at
risk
to
patients.
These
is
reallocation
of
resources
and
because
of
the
heterogeneity
of
primary
medical
services,
it
does
mean
we
can
use
different
spars
and
our
inspections
teams
to
look
at
independent
providers
and
others.
E
E
You
could
argue
that
this
is
the
time
when
we
should
have
a
scrutiny
should
have
increased.
This
is
the
time
when
the
system
was
under
greater
pressure
when
patient
experience
might
have
deteriorated,
wasn't
a
one-off.
This
was
a
predictable
and
potentially
a
period
of
several
weeks,
not
just
a
period
of
couple
of
weeks,
even
in
the
trust
that
were
rated
as
as
good.
E
Are
trusts
we
should
be
most
interested
in
because
they
are
the
ones
which
might
which
might
where
the
deterioration
might
be
greatest.
We
don't
know
so
so,
although
I
support
the
decision,
I
think
it's
very
important
that
we
now
do
the
right
thing
in
understanding
patient
experience
during
this
difficult
time
for
the
NHS
and
so
I
think
we
should
be
looking
for
a
a
greater
scrutiny
through
other
means.
So
how
we
use
data,
how
we
relate
to
the
Trust's
and
expect
to
comment
on
this
specific
issue
that
we
should.
E
We
should
be
prepared
to
tell
patients
in
the
public
how
patient
experience
was
it
affected
where
possible,
so
that
so
a
piece
of
work
which
would
correct
any
false
impression
that
we
got
the
balance
wrong
and
that
might
include
some
of
the
specific
incidents
or
here
also
every
day.
There's
a
particular
incident.
That's
happened
somewhere,
which
is
a
said
to
reflect
the
pressure
that
particularly
any
departments
are
under.
Although
I
accept
it's
not
just
any
department,
and
in
my
field
there
was
one
particular
incident.
E
A
patient
who
it
was
reported,
died
fatal
overdose
in
an
A&E
department
to
think
that
was
in
Worcestershire,
so
question
for
us,
I
think
is:
have
we
followed
that
up?
Are
we
collecting?
Are
we
looking
at
what
was
actually
happening
in
that
department
when
that
happened,
when
that
incident
occurred,
and
so
on
so
I
think,
there's
a
requirement
on
us
now
to
provide
a
sort
of
compensate
or
increase
in
scrutiny,
even
though
it
might
not
be
by
inspection.
I
just
want
some
reassurance
that
we'll
be
doing
that.
A
I
mean
my
own
perspective
is
very
briefly.
This
is
two
things
one.
Our
whole
strategy
is
to
be
risk-based
and
intelligence-led
and
I
think
this
is
exactly
what
we've
been
doing
and
and
secondly,
just
to
slightly
change
the
impression
those
you
might
have
left
there
that
we
need
a
compensation
activity,
because
I
think
the
compensator
reactivity,
as
Ted
and
Steve
are
both
said
is
actually
we've
been
moving
our
resource
to
where
we
have
the
greatest
concern.
A
J
Agreeing
with
those
verses
said,
Anna
D,
whatever
said
all
right,
but
I
understand
the
reasons
behind
the
this
decision,
but
it
prompts
to
me
for
me
a
number
of
questions.
Well,
the
first
is,
if
it
be
the
case
that
has
a
time
of
maximum
pressure.
The
way
we
undertake
an
inspection,
if
we
did,
it
would
actually
make
the
situation
worse
rather
than
better.
Then,
are
we
considering
things
made
this
point
that
I'm
putting
in
a
different
way?
J
Are
we
considering
how
we
can
visit
places
to
see
what's
actually
going
on
in
a
way
which
doesn't
produce
that
pressure,
but
at
the
same
time
protect
patients?
For
example,
we
hear
of
reports
of
20-plus
ambulances
outside
some
hospitals.
We
hear
reports
of
elderly
people
in
corridors,
sometimes
on
the
floor
or
not
even
on
trolleys.
You
see
it
seems
to
me
that
our
staff
inspectors,
our
representatives,
should
be
in
such
places
it
in
order
to
see
what
is
going
on
and
the
public
would
really
require
that.
J
That's
the
first
point.
The
second
one
is
that
the
premise
behind
this
decision
is
that
our
assessment
of
risk
is
sufficiently
good
to
enable
us
to
identify
the
places
we
need
to
go
see
to
do
just
what
I've
described
and
I.
Do
we?
What
basis
do
we
know
that
our
intelligence,
the
information
we
gather
in
real
time,
he's
good
enough
to
enable
that
to
happen?
J
And
my
third
point
is
that
if
we
don't
apply
the
same
criteria
to
the
good
and
outstanding
places,
some
of
whom
will
have
been
given
that
rating
now
some
time
ago,
and
actually
their
rating
may
may
not
have
related
to
any
observation
about
how
they
deal.
Was
this
sort
of
pressure?
Should
we
be
not
going
to
visit
them
for
two
reasons?
One
is
they
may
not
be
as
good
as
we
think
they
are,
but
actually
perhaps
just
as
importantly,
they
may
be
as
good
as
we
thought
they
were.
J
They
may
be
showing
exactly,
and
we
know
there
are
some
hospitals
which,
despite
all
these
pressures,
have
not
canceled
elective
operations
have
not
been
having
huge
waiting
times
a
day
in
here
and
so
on.
So
why
don't
be
actually
not
wasting
their
time?
We
go
there
to
trumpet
their
achievements.
I
mean.
A
F
So
in
a
sense
we
are
doing
what
you're
asked,
and
we
also
also
entrust
with
in
touch
with
ambulance
trusts,
about
any
particular
delays,
so
they
can
identify
where
they
feel
particular
pressures.
There
are
in
the
system
as
well
and
that
will
inform
our
approach
to
individual
services,
so
I
think
we
are.
We
are
trying
to
do
that.
I
mean
we
can't
be
everywhere
all
the
time
and
the
situation
Department
can
change
hour
by
hour.
F
So
inevitably
we
cannot
see
everything
that
goes
on,
but
what
I
would
stress
and
I
think
it's
important
that
we
get
this
message
across.
If
you
read
our
reports
from
emergency
departments
over
the
whole
year,
you
will
see
elements
of
this.
The
system
is
under
pressure
at
the
moment
and
that's
particularly
so,
but
we've
been
reporting
our
concerns
about
emergency
departments
throughout
the
year
and
you'll
see
reports
from
the
summer
where
supposedly
missions
bottoms
are
turn
to
winter
pressures,
where
we
found
unsatisfactory,
unsafe
care
and
taken
action
as
well.
F
M
B
M
B
But
I
want
to
take
the
opportunity
just
to
clarify
something
which
I
think
has
been
a
bit
muddied
and
a
bit
opaque,
which
is,
we
do
have
new
powers,
but
those
new
powers
do
not
give
us
the
ability
for
CQC
to
reach
health
applications,
apps
or
websites,
and
it's
quite
important
because
I
think
there's
a
narrative
out
there
at
the
minute
that
we
do
do
that.
We
do
not
do
that.
What
we
do
is
we
read
the
services
that
people
might
access
through
an
app
not.
C
B
App
itself
and
what
we're
trying
to
say
in
this
very
final
paragraph
of
this
is
that
we
are
going
to.
We
are
doing
we've
begun
to
do
some
work
with
other
arms-length
bodies
who
have
all
the
sites
or
some
of
those
services
to
make
sure
that
there's
absolute
clarity
between
the
organization's
about
what
the
respective
responsibilities
are
and
then
just
going
back
to
partly
the
conversation
or
about
Peter
that
the
public
can't
take
an
assurance
that
we
are
looking
at
these
things.
When
we're
not.
B
It
is
the
importance
of
the
assurance
we
give
a
thing,
which
is
the
point
that
Luis
was
I,
think
getting
up
behind
his
question
and
that's
what
we
want
to
do
and
I'm
not
going
to
do
the
publication's.
You
can
read
those
and
we've
covered
the
appointments.
So,
if
I
conclude
the
report
there
Peter.
Thank
you
great.
A
C
While
we've
been
focusing
on
some
of
the
core
comprehensive
inspection
program
over
recent
years,
but
also
because
I
think
they
highlight
some
of
the
work
that
we
do
in
support
of
some
of
the
most
vulnerable
populations,
whether
that
vulnerable
children,
those
looked
after
people
detained
in
the
secured
estate
for
a
whole
range
of
reasons.
Those
in
immigration
detention
centres,
as
well
as
those
in
prisons
and
secure
facilities
for
young
people.
I
hope.
C
In
the
same
way,
as
we
hope
to
see
that
sort
of
partnership
in
terms
of
how
those
systems
are
are
working
together
and
this
team
in
relation
to
their
work,
whether
it's
with
Ofsted
Her,
Majesty's
inspectors,
prisons
and
Constabulary
and
probation,
have
been
doing
this
work
for
some
time
and
have
been
over
the
last
year
or
so
particularly
sharing
internally,
with
their
local
systems,
review,
team
and
others.
Some
of
our
learning
in
those
areas,
I
hope.
C
The
feedback
that
we
get
from
send
inspections
from
individual
prisons,
about
the
impact
that
our
work
has
through
our
reporting
and
regulatory
action,
but
some
of
our
highly
impactful
thematic
reviews,
again
often
done
in
in
partners
with
the
budget
with
other
agencies
and
on
areas
like
domestic
violence,
child
sexual
exploitation
and
misuse
of
substances
in
the
secured
estate
and
being
asked
to
contribute
through
things
like
the
independent
inquiry
into
child
sexual
abuse.
We
were
asked
to
present
evidence
and
go
back
subsequently
to
some
informal
sessions.
C
Offering
advice
on
the
recommendations,
much
of
the
credibility
of
my
friend
Nigel
here
I
think
there
are
a
couple
of
things
that
are
really
important
to
that
success.
I
think
one
thing
that
we
do
in
our
methodology,
which
isn't
routinely
shared
by
some
of
the
other
methodologies
in
CQC,
is
the
use
of
case
tracking
and
people
find
the
powerful
messages
that
we
get
out
of
tracking
a
child
right.
The
way
that
way
way
through
the
system
gives
a
real
granularity
and
really
helps
both
local
systems
and
often
a
thematic
review
to
identify.
C
Where
were
those
will
pinch
points
and
critical
moment?
Sometimes
what
opportunities
were
maximized
for
improvement
and
sometimes
what
opportunities
were
lost
and
I
certainly
know
we're
having
a
conversation
with
some
of
the
other
teams
who
do
some
of
this
work?
Although
it's
a
little
bit
labor-intensive
I
think
there
is
a
real
benefit,
cost
benefit
equation
to
have
for
it
when,
when
judiciously
applied
in
those
areas
where
you're
really
trying
to
get
underneath
what
is
going
on
and
what
is
the
impact
in
terms
of
that?
C
That
is
that
is
happening
and
I
know
that
Nigel
we
want
so
that
in
certain
areas,
for
example,
the
send
inspection
program
has
been
really
powerful,
I
think
in
capturing
some
of
that
stuff
and
has
been
reflected
back
to
us
on
occasions
where
it's
the
first
time.
Sometimes
local
stakeholders
have
got
together
to
prepare
for
the
evil,
inspection
and
actually
has
carried
on
having
conversations
afterwards,
because
they
recognized
how
useful
it
was
to
join
up
some
of
those
relationships
across
the
system
in
line
with
other
parts
of
CQC.
We
share
some
some
common
challenges.
C
And
the
big
example
at
the
moment
is
shortage
of
prison
officer
and
other
staff
able
to
escort
patients
to
the
services
and
appointments
that
they
needed
to
go
to
really
complex
about
where
you
hold
that
to
account
through
the
provider
who,
on
the
one
hand,
is
failing
to
deliver
services.
But
it's
another
partner.
That
is
not
enabling
that
to
happen.
And
how
again
do
we
speak
that
truth
to
power
in
terms
of
what
it
is,
that's
really
causing
that
that
pressure
in
the
system?
C
What
should
our
expectations
be
of
providers
in
those
circumstances
about
how
they
are
respected,
responding
and
flagging
some
of
those
risks,
while
not
getting
into
situations
of
blaming
them
and
holding
them
to
account
for
that,
for
which
it
is
very
difficult
first,
but
them
to
be
accountable,
I
proposed
to
stop
there.
No
I
do
everything
you
wanted
to
add.
No.
N
I
think
I
think
I
would
have
I
would
have
covered
I
think
just
to
emphasize
I
think
that
the
team
that
carry
out
these
inspections
there
were
national
team,
very
specialists
in
nature
there,
quite
intensive
inspections
and
I.
Think
if
you
looked
at
the
staff
survey,
results
you'll
see
that
both
teams
were
amongst
the
most
positive
results
in
the
Commission
and
I.
Think
that
reflects
I
think
the
value
that
they
see
they
get
from
these
inspections.
They
see
that
the
inspections
will
be
doing
the
nature.
N
N
So
our
foot
really
in
the
door
in
relationship
in
relation
to
the
joint
inspection
work,
is
quite
a
different.
We're
working
with
inspectors
have
got
quite
different
cultures
to
ourselves,
but
I
think
by
doing
that,
hard
work
and
some
of
those
those
inspectors
here
today,
as
the
work
they've
done
in
engaging
with
other
inspectors,
we
have
a
very
credible
relationship
with
other
inspectors
and
you'll
notice.
N
I
think
we've
certainly,
for
example,
do
a
lot
of
work
with
the
Ministry
of
Justice
home
office,
D
F
ADH,
we're
always
called
to
the
table
as
equal
partners
and
certainly
administers
justice,
talked
to
us
last
year
about
raising
the
profile
of
health
within
prisons.
We
were
critical
partners
in
that
discussion.
We
were
called
alongside
H
my
opinion
I
wanted
to
talk
to
us
separately
as
well,
so
we've
seen
is
very
important
in
that
in
that
dialogue
and
finally,
just
other
comments.
N
Agencies
in
a
local
area
are
required
to
come
together
to
talk
to
us
and
when
we
go
away
without
that,
we've
had
numerous
examples
of
where
agencies
have
recognized
the
value
of
talking
to
each
other,
and
they
continue
those
conversations
after
we've
left
I've.
No
doubt
that
has
a
significant
impact
on
on
the
way
and
we
services
are
provided
so.
A
Just
before
I
get
out
can
I
just
say
that
it
seems
to
me
that
that
the
areas
you're
working
you
know
are
in
many
respects,
some
of
the
most
challenging
that
we
work
in
the
environment.
The
fact
that
the
providers,
as
you
say
us,
they're,
actually
in
control
of
a
lot
of
the
factors
that
get
in
the
way
of
delivery.
A
My
sense
Steve
is
that
really
to
support
what
what
nighted
and
Ursula
both
said
that
the
partnerships
that
are
now
involved
are
working
really
well
and
we're
not
seen
as
trying
to
gatecrash
or
or
we're
not
in
competition
with
each
other.
It's
now
beginning
to
work
extremely
well.
Is
that
how
you
see
it
I
see.
E
Luis,
it's
really
good
that
this
has
come
to
the
board.
I.
Do
I
really
think
this
is
up
there
with
the
most
important
work
that
we
do
part
of
good
thoughts.
The
reason
Steve's
just
said:
they're
some
of
the
most
vulnerable
people
in
the
system,
some
of
the
people
with
previous
neglect
and
high
high
rates
of
most
of
the
problems,
health
and
social
problems
that
we
should
be
concerned
about.
So
it's
really
good
that
you're
here
and
to
see
the
progress.
E
You
know,
sort
of
clinic
appointment
and
treatment,
and
an
issue
of
escorting
is
the
problem.
But
on
this
wider
issue
of
the
ethos
of
institutions,
as
you
know,
I
went
to
a
prison
recently
and
it's
just
a
reminder
of
the
of
the
the
environment
and
the
way
that
the
environment
can
have
an
impact
on
people's
health,
and
we
just
would
not
accept
in
health.
E
The
environment
in
which
vulnerable
psychologically
damaged
people
are
after
in
prisons,
and
although
these
aren't
necessarily
health
care
facilities,
although
they're
not
great
either,
and
these
are
vulnerable
people
in
institutional
care,
looked
after
essentially
by
the
state
and
I.
Just
wonder
whether
we
are
able,
as
the
health
care
inspector
to
have
that
if
that
influence
on
the
wider
system
and
just
where
we
go
I've
got
a
second
point.
This
is
that's
okay
and
it's
the
point.
E
Just
wonder
whether
there's
any
way
in
which
we
can
highlight,
though,
what
happens
to
those
people,
they
seem
to
be
a
really
good
example
of
what
we're
trying
to
do
now,
which
is
understand
the
the
pathway
that
people
are
on
the
movement
of
people
between
services.
Not
just
look
at
this
individual
service.
You
know,
that's
the
those
are
the
people
you
might
start
with.
If
you
were
taking
that
approach,
I,
just
wonder
whether
we
should
be
doing
more
about
what
you're
finding
for
those
young
people.
C
So
I
think
in
terms
of
the
wider
system
issues,
particularly
in
relationship
prisons,
but
also
in
terms
of
Children's
Services
I,
think
we
have
had
an
we'll
have
more
impact
on
two
or
three
different
levels.
So
the
first
one
and
I
had
general
nod
so
experice
are
in
inspection
manager
for
their
health
and
justice
team.
C
The
IP
has
recently
introduced
a
new
framework
for
their
own
assessment,
where
health
services
fit
within
the
respect
domain,
but
also
under
the
healthy
prisons,
policy
and
I
think
that
I
think
we
had
a
lot
of
input,
but
in
how
the
hmit
themselves
thought
about
that
domain
and
the
issues
in
relation
to
their
healthy
prison
environment,
as
well
as
the
issues
about
specific
health
services
and
I,
think
we
are
continuing
to
push
on
that
open
door
of
how
it
is
that
we
get
how
we
might
have
a
greater
role
in
assisting
with
with
the
assessment
and
evaluation
of
some
of
those
wider
health,
particularly
some
of
the
public
health
and
health
and
well-being
aspects
with
within
the
the
Prison
Service.
C
And
that's
certainly
what
we
will
be
discussing
with
her
Majesty's
inspectors
of
prisons
in
our
in
our
annual
review
meeting,
and
it's
one
of
the
reasons
why
we
think
it's
so
important
that
our
inspectors
continue
to
have
free
reign
across
the
prison
estate
and
so
that
they're,
not
just
confined
to
being
escorted
to
the
health
block
and
escorted
out
about
block.
We've
had
conversations
about
the
the
risk
of
that
in
terms
of
our
inspectors
being
key
carrying
through
the
estate.
C
But
on
balance
we
think
that's
absolutely
the
right
thing
to
do,
because
it
gives
us
the
ability
to
comment
and
working
with
the
dedicated
health
inspectors
from
from
HMI
IP
in
into
those
assessments.
I
think.
The
second
thing
is
the
work
that
we've
done
within
some
of
the
thematic
reviews,
which
again
pull
pulls
that
together
and
seeks
to
create
a
bigger
narrative
and
put
that
narrative
up
into
policy
and
secondary
I.
Think
we're
particularly
pleased
that
two
or
three
really
important
strategic
issues
have
now
been
picked
up.
C
That
meant
that
they
gave
up
into
the
prison
estate
and
certain
we've
had
that
conversation
in
the
context
of
the
child.
Adolescent
mental
health
services
thematic
review,
which
you
also
know
that
we're
doing
about
what
is
it,
but
actually,
particularly
in
terms
of
their
qualities
and
inequalities
agenda.
C
That
means
that
some
people
will
end
up
in
the
justice
system
and
some
people
will
end
up
in
a
tearful,
secure
bed
and
that
sometimes
the
it's
the
issues
of
background
and
a
range
of
other
things
around
opportunities
that
distinguish
what
happens
to
a
distressed,
14
or
15
year.
Older
is
beginning
to
exhibit
difficulties
about
whether
that's
regarded
as
illness
or
delinquency.
A
Great
time,
thank
you,
I'm
gonna
bring
this
to
an
end,
not
because
it's
not
really
interesting,
but
I.
Just
we
are
so
late,
but
I
think
you
would
have
picked
up
from
what
Lois
certain
and
certainly
what
I
think
this
is.
This
is
such
an
important
area
and
a
very
difficult
environment
for
our
people
and
I,
just
like
to
echo
I
I,
think
the
whole
boards,
thanks
to
your
staff,
collectively
for
all
that
they
do
so.
Thank
you
very
much.
Indeed,
everybody.
A
E
Two
topics:
one
was
mental
health.
We
heard
about
the
inspection
program
where
a
third
of
mental
health
trusts
have
been
rated,
requires,
improvement
or
inadequate
and
mostly
requires
improvement.
Two-Thirds
have
been
rated
good
or
outstanding,
mostly
good,
and
subsequently
on
re-inspection.
To
pick
up
the
point
we
discussed
briefly
earlier
and
there's
a
reasonable
improvement
story.
E
E
So
some
very
forward-looking
positive
account
of
where
mental
health
has
got
to
second
theme
of
the
of
the
meeting
was
a
was
actually
a
a
report,
an
interim
report
really
of
an
internal
investigation,
an
incident
that
had
it
was
raising
questions
about
some
of
CQC's
approach,
particularly
on
the
issue
of
fit
and
proper
person
regulations.
So
there
was
a
discussion
about
that.
E
Do
we
when
something
happens,
an
incident
happens
and
we're
concerned
about
the
implications
for
how
we
work
and
do
we
have
a
proper
process
for
initiating
an
incident
for
reporting
it
for
the
the
governance
of
the
learning
and
so
on,
and
what
came
out
of
that
incident
review
was
in
particular
that
we
ourselves
need
an
incident
investigative
process
which
is
a
little
bit
more
formal.
A
little
bit
clearer
for
people
and
although
the
meeting
didn't
conclude
on
that,
we
are
expecting
to
receive
a
further
report
on
how
that
might
go.
Thank.
A
You
so
it
was.
It
was
a
very
good
meeting
yesterday.
Is
there
any
other
business
that
the
board
wanted
to
raise
great,
so
I
think
that
is,
that
is
that
mr.
Ward
I
hope
you
think
you
had
a
pretty
thorough
answer
to
that.
Your
question
I
hope
you
also
got
copy
the
letter
that
I
sent
you
in
answer
to
your
question
from
the
previous
board
meeting
I've
not
got
any
other
questions
from
members
of
the
public
or
actually
here
so
with
that
running
very
late,
we
finished
the
meeting.
Thank
you
very
much
indeed,.