Care Quality Commission Board meetings, 19 Feb 2014

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From YouTube: CQC Board Meeting 19 February 2014

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Agenda for the meeting of the Care Quality Commission Board held on Wednesday, 19 February 2014:

01. Apologies and declarations of interest 0:00:01
02. Minutes of the meeting held on 22 January 2014 0:00:53
03. Matters arising and action log 0:00:57
04. Chief Executive's Report 0:01:30
05. Chief Inspector of General Practice - update 0:41:37
06. Chief Inspector of Adult Social Care - update 0:58:53
07. Chief Inspector of Hospitals - update 1:15:01
08. Q3 Corporate Performance Report 1:23:43
8A. Complaints Report 1:36:13
09. Draft Business Plan 2014/15 1:44:43
11. New Approach to Thematic Activity 1:57:17
12. Report from Audit and Corporate Governance Committee meeting - 28/01/2014 2:18:47
13. Report from Regulatory Governance and Values Committee meeting - 21/01/ 2014 2:23:31
14. Report from Healthwatch England 2:54:57
15. Board forward plan 2:55:10
16. Any other business 2:55:51
17. Questions from the Floor 2:56:54

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

A

≫≫ Apologies and declaration of interest, I made a cock-up of my declaration of.

A

Interest,, we have to declare all our interests, not just what I thought the.

A

Conflicts of interest,, so Private Eye very helpfully pointed this out to me!.

A

But I am getting our conflicts of interest, I mean our declaration of interest policy.

A

Updated so it is --, it is ten years old ours,, so I will get that done.

A

I thought, Michael, I might get our GB committee to look at that. Please,.

A

So, apologies for me for making a mistake on that.

A

Everyone else feels happy that they know what their policy is?.

A

But I will get it recirculated to people anyway.

A

Minutes of the meeting, everyone happy?.

A

Matters arising?

A

I think we pick most of them up during the meeting,. There is just one which we.

A

Said that we would write to the DH setting out our expectations for.

A

Legislative independence,, this was discussed in the latter stages of the.

A

Care Bill over the last ten days, so we'll do that over the next few weeks.

A

Paul, I was wondering whether you might just help us think that, through, if you could?.

A

Particularly, in view of the Ofsted discussions over the last few weeks,.

A

A

Chief Executive's report, David?.

B

≫≫ Thank you, good morning everybody, some updates on progress,.

B

First, one is the Care Bill,. This has now completed committee stage,.

B

It's about to go into report stage and I anticipate Royal Ascent towards the end.

B

Of March,, beginning of April.

B

Of significance for CQC, it's a very full bill and has lots of significance for.

B

Others as well,, but they considered our role in relation to financial oversight,.

B

The duty of candour and how we assess the performance of local authorities and.

B

That has continued to be an issue.

B

I've set out in this brief update a report on those issues.

B

On the duty of candour: this is now introduced, regulations will be issued,.

B

This will be given form by the regulations and they will be available for.

B

Consultation in the next few weeks, that will see a bigger debate about this issue,.

B

About how it will operate and what the implications will be.

B

Financial oversight, the debate in the committee stage, in many respects.

B

Reflected what the Health Select Committee were reflecting back to us,.

B

In relation to skills, expertise and experience within CQC in relation to this.

B

Role, and I don't think any changes were made in relation to the face of the bill,.

B

So we'll continue to build and grow our capacity in relation to that responsibility.

B

The debate on commissioning, however, has continued to take some form,.

B

With quite a lot of energy being directed to this particular issue.,.

B

The bill as it currently stands, requires two secretaries of State, committees.

B

And local government and health to request us to carry out a review of.

B

Commissioning practices as part of a special review,, that's using our Section.

B

48 requirements.

B

The energy behind this is really about concerns around poor commissioning,.

B

Predominantly of domiciliary care in 15, minute visits,, but also concerns around.

B

The quality of residential care for older people in the main,, but nevertheless it.

B

Also has implications for people with learning disabilities.

B

Paul Burstow at the very end of the committee stage, did move amendments.

B

In relation to the role that we might play,, which will be taken forward and as I say,.

B

I think what we need to do in this is let this settle, I think our position. David is, if.

B

We're asked to do this: we will do this., I think going back to the market oversight,. My view is, if we needed to do.

B

A review of commissioning of local authorities,: this would be more akin to.

B

The kind of inspections that the Social Services Inspectorate did in days gone.

B

By and we need to design and build methodologies that would allow us to do.

B

That and we'd need to think about the skills that we would need to actually.

B

Carry out that kind of investigation,, it's a different investigation to actually looking.

B

At whether the regulations are actually met in practice,, because there aren't a.

B

Set of regulations around local commissioning as much as anything else.

B

So, it's closer to the work that we're doing in reviewing the health.

B

Contribution to children, safeguarding than it is to our regulatory activity.

B

So, if we're asked to do that, we will do it and,, but we'd need to build both a.

B

Methodology and capability to do that.

A

≫≫ Can I, add to that, Norman Lamb in particular is concerned that a 15.

A

Minute domiciliary care visit is not enough,. He is concerned that the.

A

Amount of money being paid per carer for people with dementia is not enough,.

A

Those sorts of issues,, but it reflects a squeeze on finances in the world of local authorities.

B

≫≫ I think it's --. Now it's gone through the committee. Stage, I anticipate this.

B

Working its way through and this will get Royal Ascent, so I think we need to.

B

Prepare for this with a view to this is something that we're going to be.

B

Asked to do, not something that will evaporate along the way.

B

Not mentioned in the report,, but an update that I became aware of following.

B

The development of the report, there was also a debate in the committee stages.

B

About whether we could use our powers to issue warning notices for a Trust.

B

Which are going into special administration, regime, and I think what.

B

Mps were anxious to do was not get Trusts into a double whammy where.

B

We're taking enforcement action, warning notices and going into the.

B

Failure regime,, which makes good sense, you can't do both together,.

B

It's one or the other. We previously had discussions with both the Department and here I think about.

B

Us having our range of,, our pallet is the phrase we've been using of regulatory.

B

Actions available to us in hospitals,, so it's not either you're in the failure regime.

B

Or you're not, that there is a finer tone, required, finer colours required in the.

B

Way we actually take forward our enforcement action in relation to Trusts.

B

If the only tool we have in our toolbox is a hammer. Then it will lack subtlety in.

B

Relation to what we can do for what we find, so I think this is an.

B

Acknowledgement of that, but also not wanting us to actually be using both.

B

Warning notices, enforcement powers and the special administration regime at the same time.

B

So, that's the Care Bill,, some updates in relation to the transformation.

B

The preference exercise,, where over a thousand of our inspectors and.

B

Managers had got to state their preference through working in Mike's.

B

Inspection directorate,, Steve's or Andrea's,. That's now, complete.

B

And the fantastic position we're in is that everybody will get their first preferences met.

B

Some staff,, because in one or two geographical areas and in some of the.

B

Inspection directorates we've got too many people at the minute, as we start,.

B

For the original allocations, and therefore it means we've not got enough in some.

B

Places so we need to smooth that because we've got work to deliver from.

B

The 1st of April,, but that can be done just by loaning people back.

B

And asking people to continue to inspect across more than one sector.

B

Paragraph 3 on this we've set out what we'll do to recruit over 500 new staff.

B

During this year,, as we get that recruitment in,, then people can go back.

B

To their first preferences- and it won't be an issue.

B

Paul's, staff in strategy and intelligence are going through a preference exercise.

B

At the present time, completed now is it?.

C

≫≫ Completed for the intelligence staff and all bar 4 people got their first.

C

Preferences, we're just validating that and that's what it looks like at the.

C

Moment and we're going through a similar process in strategy and policy.

B

≫≫ So that's proceeding well. I have to say.

B

The other important piece of work: that's going on now, now we know where.

B

People's destination is and where they're leaving from,, we need to make sure that.

B

If they're not taking work with them, that that work is handed to somebody else,.

B

That there is a baton,, it's not that they leave, they have to leave,, give their work.

B

To somebody and then they can depart, that's what we want to see in relation to.

B

Any regulatory activity,, but particularly enforcement activity, and just a process.

B

Of managing people that are making complaints or sharing intelligence with.

B

Us about the quality of services which need to be picked up, and the risk that.

B

We lose vital intelligence because of a discontinuity of people is what we're.

B

Trying to mitigate with this.

B

The other piece of work, which is going on,, Hilary's team with PWC taking the.

B

Lead in this, is a readiness assessment which is actually assessing our.

B

Readiness to hit the 1st of April and take on the new methodologies so we're.

B

Good to go from that and that's about making sure we have the right people in.

B

The right place, we have the right methodologies,. The tools are there that.

B

People have got the preparation in terms of what we're asking them to do,.

B

So the next six or so weeks will be responding to those readiness.

B

Assessments and making sure we have the appropriate actions in place.

B

On paragraph 3 David, the recruitment,, we're flagging up here that there's three.

B

Components to the recruitment activity that we need to undertake and we're.

B

Looking to source a recruitment partner to bring in, to help us through those.

B

Three distinct projects,, that's an attraction and engagement and then.

B

A delivery on recruitment services,, so we've formed a relationship with Penna.

B

In relation to that and the second one,, the assessment design,, that's currently.

B

Out to tender, and that will give us the additional capacity that we need to.

B

Actually make sure we can get new people into the jobs that we're creating.

B

As part of this work.

A

≫≫ Eileen,: do you want to comment on that at all?, I know you're new to it,, but you're. Looking at it.

D

≫≫ In essence: as David outlined,, we are facing a volume recruitment.

D

Challenge,, which is we are attempting in 2014-15, to bring in a minimum of 500.

D

New professional people into the organisation to carry out inspection.

D

Activities and to support in Paul's area, around strategy and intelligence.

D

When, you undertake volume, recruitment of professional people who.

D

You want to be recruited safely and securely, and you know you're not going.

D

To be doing that every year,, it is sensible to seek partners to work with you to.

D

Make sure that you're bringing people in, in the right way, that you're assessing them against what your requirements? Are,, that your roles are.

D

Absolutely properly specified and that for us in, as David's alluded to,, where you.

D

Have some geographic areas where traditionally, we've had difficulties in.

D

Recruiting that we are actually targeting our efforts very specifically at trying to.

D

Get people into those areas. That's the rationale behind it, we're pushing very hard on value for money.

D

And also choosing our partner or partners very carefully as well David.

B

≫≫ At four I've, just shared with the board an important piece of work which.

B

Was a survey of the attitudes of providers in relation to CQC and our.

B

Role, there's a report attached which I'll not attempt to present,, but it covers.

B

Important issues like the nature of the relationships between providers and CQC.

B

Their view about the balance between announced and unannounced inspections, I think the top line message from this is they want an.

B

Effective regulator and there's a powerful message about how they define effective.

B

The eagle-eyed of you will have worked out that the interviews didn't take place.

B

Between June and August 2014, because we've got many powers, but that.

B

Isn't one of them! So that should be 13.

B

We've got a sequence of these independent reports being commissioned to give us feedback about how people regard us and acting.

B

On those lessons that come through from this.

B

This report will go on our website this morning and by virtue of being.

B

Presented here will become a public document and then it's available for.

B

Others to look at. Not in the report,, but only published this week, David, is the mental health.

B

Crisis care- concorda, I've referred to this previously, but we're a signature to this.

B

And we committed,, along with just about every major statutory and voluntary.

B

Organisation working in mental health to support this Crisis Care Concorda, which.

B

Is effectively people committing to improve the care and support system for.

B

People in crisis, because of a mental health, condition.

B

Our role really is to carry out the thematic work that we've already.

B

Committed to in terms of crisis care,, but also to look at the collection of data.

B

Along with other agencies,, so there's a fuller report which is available.

B

If members of the board would want to see it, we've had some excellent work.

B

Done by a member of Paul's team, with the Department of Health and other.

B

Colleagues, to make sure that our contribution to that can be represented.

B

And we can play our part in that.

B

Then, the last, I just want to -- last item to draw attention. To, appointments.

B

Andrea and Steve and myself have spent a couple of weeks, a couple of.

B

Weeks ago, spent some time interviewing and on adult social care for deputy chief.

B

Inspectors we've appointed Debbie Westhead who's, currently head of.

B

Regional compliance in the north region, she covers the northeast,.

B

As one of Andrea's deputy chief inspectors, Malcolm Bower Brown, the.

B

Current regional director goes into one of the posts anyway and Adrian Hughes.

B

Who's the current director for the south,, because he was acting regional director.

B

Has been interviewed and secured that post,, so what that means is we have.

B

One vacancy with Andrea and we're trying to source that appointment and.

B

That will cover the London area and also lead on the market oversight. Work.

B

On primary medical, services,, Steve's area, Matthew Traynor, is the current.

B

London regional director, as you know, Matthew, will take the deputy chief.

B

Inspector role for London, but will also lead on the work we do around integrated care.

B

Sue McMillan who's. Currently, the policy lead in relation to mental health,.

B

She will take one or the other deputy chief inspector roles covering the north,.

B

She will lead on safeguarding and health and justice,, so the inspection roles and.

B

Responsibilities which she's a continuation of the some of the.

B

Responsibilities she's had to date.

B

That means that for the south region and the central region, we've still got.

B

Vacancies, now on the central region, I think we're in the process of completing.

B

The due diligence on an external appointment,- that's not completed and.

B

That person has not given notice to their employer yet,, so we're not able to.

B

Announce that,, but that then means we've got one vacancy for the south and.

B

Again, we continue to look to secure an appointment for that,, so we've been.

B

Holding on to make sure we only make appointments of people we're confident.

B

In and it will take as long as it takes to get those appointments in,, but we've.

B

Made good progress on that and will continue to push that.

B

Heads of inspection posts will then go out for inspection and we'll begin to build.

B

Those teams and the contract we talked about with Penna and whoever gets that.

B

Third, contract, is really about getting the managers and inspectors into the.

B

Vacancies that we've got, so as we work through this back-end of the winter and.

B

Early part of the spring, that should see quite an extensive recruitment process.

B

To bring this up to capacity,, although I do think it's likely to be the summer before,.

B

If not into the early part of autumn,, before we have the majority of people in.

B

That we are looking to secure this year.

B

I think that's all of it: David, thanks.

E

≫≫ David, could I just add something briefly to what David said about the.

E

Study into provider, attitudes and behaviours?.

E

One of the points David didn't mention was the finding that there is still anxiety.

E

About consistency of judgments in the regulatory system.

E

Now, that's fundamental to the credibility and the effectiveness of a regulator,.

E

We do have to insist: that, demonstrate that we are able to operate a fair and.

E

Equitable system of judgments, and I don't want a long explanation now, but at.

E

Some point I think it would be helpful if the new systems that have been.

E

Developed by the three chief inspectors could be highlighted, to demonstrate.

E

How that fairness and equity is being built into the system, through a process.

E

Of moderation and quality assurance and so on.

A

≫≫ I think consistency is absolutely fundamental,. I think all the chief.

A

Inspectors know that,, but I think we do need to have a report back to the board.

A

About how we're going to entrench a fair system,, so can you make a note of that,.

A

F

≫≫ Absolutely.

A

≫≫ Steve, as well?.

B

≫≫ I think the last board asked for a report and agreed that it would come in.

B

October on exactly that, point. But I know Mike spent hours in meetings trying to get the calibration.

B

Across the ones coming so far,, so whilst we're doing the live, work, we're.

B

Continuing to spend time on that.

B

The point's made,, sorry, John, I didn't leave it out,. It was just what --.

B

I cherry picked,, badly.

G

≫≫ Just to add to John's point, the other thing that I thought came out very.

G

Strongly from this paper was across the board providers saying that there.

G

Is a lot of bureaucracy, and there was one alarming quote from a mental health.

G

Provider about they think they're, probably not improving the service.

G

Because they're spending so much time on compliance, again I wonder if.

G

We can come back to that at some point,. Also concern about overlap between.

G

Regulators,, which a lot of providers feel very strong about, I would like to hear.

G

Quite soon how we're going to mitigate that,, if that's all right?,.

A

≫≫ In particular between Monitor and us and hospital centre.

G

≫≫ I think the more we can streamline what we're asking for with other.

G

Regulators, the easier it will be for providers.

G

The fact that so many people in here had compliance teams. You can see as.

G

Good or bad, great, they have huge numbers of people working on our.

G

Inspections but those people could be delivering the service.

G

It's, not something we can solve unilaterally, but I do think it would be.

G

Good to keep it top of mind just given how strongly it comes out of this paper.

A

≫≫ You can probably build that into the work you're doing on strategic measures can't you?.

C

≫≫ We can, and also there is work that Andrea and I have been doing or leading.

C

For the Department of Business Innovation Skills review on just this in.

C

The care home sector,, particularly that overlap between the local authority.

C

Inspections or compliance regimes and ours, and we've taking quite a hard line.

C

On the changes to our model are what should give others a lot more.

C

Reassurance and therefore they shouldn't need to duplicate some of the.

C

Work that we're doing,, which will help providers.

A

≫≫ Okay, thanks, Louis?.

H

≫≫ If I can make a couple of points,. First one is on a similar theme.

H

I was struck in the report by how the providers were talking a lot about.

H

Managing CQC and their visits, and, of course that could mean lots of different.

H

Things,, but most of them are not very positive,, it does suggest there is still.

H

What has hung around inspections of all kind, not just in health, but in education,.

H

A sense with which the inspectorate has to be dealt with and presented with.

H

A picture,, which is what they want to hear about rather than to get to the sort.

H

Of reality of practice.

H

And, it did strike me that putting that with the fact that some people are saying.

H

They didn't quite know what we were looking for,, that presumably there will.

H

Be,, the inspectors must be planning some sort of reliability exercise,. There.

H

Must be an induction somewhere in the pipeline which ensures that what.

H

Inspectors in one place are seeing something similar to inspectors in.

H

Another, between one sector and another sector.

H

But, it strikes me that people who are at the moment, thinking of managing CQC.

H

Should be part of that process, so they can be also in a sense inducted into a.

H

Method as opposed to managing it as an external force.

A

≫≫ On that point; Andrea. Do you want to give your reflection on that?.

F

≫≫ Yes I think I can. Just to give Louis and the rest of the board some reassurance about how we.

F

Are going about that and we actually spent quite a lot of time yesterday in the.

F

Executive team, looking at two aspects that will help.

F

One is what the lines of inquiry are, that we're expecting our inspectors to use in.

F

Terms of the inspections that they do and secondly,. How do we describe the.

F

Judgment framework which actually make it is clear what we think good.

F

Looks like,, but also what we think outstanding, requires improvement and.

F

Inadequate looks like, and you'll see this when we come out for consultation in.

F

The spring with the handbooks and that will be set out.

F

So that people will see that, and the whole point of that is to be absolutely.

F

Clear about the five key questions that we're asking,, which we know are the.

F

Things that matter to people who are using services, applying our.

F

Methodology in that way,, so actually it's not about dealing with the inspectorate,.

F

What we're actually expecting people to do is what they should be doing anyway.

F

To deliver a quality, service.

F

So trying to tie those two things: together.

F

And, then the final point about co-production, which is essentially what you were just suggesting there,, that's absolutely how we're going about it,.

F

So the conversations that we're having in the adult social care co-production.

F

Group involves people in the provider sector, as well as others,, who are.

F

Compliance managers or whatever,, who are actually helping us to think through,.

F

How do you ask these questions in the way that draws out the information that.

F

We need to make the judgments that we need to make.

F

But, we'll have lots more bites at this cherry.

A

≫≫ Can, you just comment on that? Do. You feel our team are being managed by some hospitals?.

I

≫≫ The whole issue of consistency is probably takes up more of our joint time.

I

Than anything else,, so I can assure fellow board members that we really are.

I

Devoting a huge amount of energy to it,, it is also the most difficult thing.

I

And by the time we are looking at a whole range of different core services,.

I

And we are looking at five key questions on each and we've got to try and be.

I

Consistent in the way that we reach judgments on all of those different.

I

Items,, it is tricky,, but we are, I, think the approaches we've got are to make sure.

I

First of all that we train the people on the inspection teams,, our own inspectors,.

I

The team leaders and the external experts that are coming to join us,.

I

I think we have to have absolutely clear guidance, as Andrea said, about what.

I

Constitutes good so they know that, and then importantly, certainly at least in the.

I

Hospital sector, where we've got relatively smaller numbers than either Andrea or.

I

Steve have got, all the reports are coming to a national quality assurance.

I

Group,, so we are reading each one and trying to make sure that we are being.

I

Consistent,- and it is one of the reasons we decided not to rate the first 18,.

I

Because we were absolutely aware that there were difficulties, here.

J

≫≫ Thanks very much David,, also on the report. A couple of things which struck me.

J

One of which was this preference for unannounced inspections and the other.

J

Was the desire to identify more clearly what the CQC requires, so people do --.

J

And what was required to fulfill those requirements,- and it strikes me about.

J

Both of those that they go to the heart of what we want from well led.

J

Organisations, that actually responsibility for understanding and interpreting what.

J

The standards require is something that one would expect. Leaders of the.

J

Organisation to wrap their heads around and make clear to the organisation,.

J

And that there's something about unannounced inspections,.

J

They absolutely have their place,, but of course, one of the reasons why people.

J

Are expressing a preference seems to me to be because they want CQC to.

J

Perform their own internal audit/quality assurance functions for them.

J

And, that, clearly, is not what we're there for,. We might, coincidentally, be helpful in.

J

That respect, but it's not the primary purpose of our inspection, regimes.

J

And I suspect- and this is a hypothesis, but I suspect that both of these are.

J

Issues --, if these are reflections of larger organisations, I, think our answer is this:.

J

Is about well led,, but I suspect that these are two things which will crop up.

J

Particularly for some of the smaller organisations where they don't have big.

J

Compliance functions and actually our visits are an opportunity to help them get.

J

Things right in many respects. I just think at some stage,. That's something I recognise from other.

J

Regulated sectors,, the small organisations have very particular.

J

Issues, I think at some stage we need to take the opportunity to look at small.

J

Organisations across our environment and see how their needs are different.

J

And their interests are different and whether we need to flex our approach.

J

With regards to them., It will particularly affect Andrea's area,, but it will affect primary care in a big way.

J

As well, so it's not just a social care issue.

F

≫≫ A couple of issues, in terms of defining what good looks like,.

F

I urge caution from previous experience,, because there is a tendency for.

F

Providers to pressurise us into being absolutely explicit about what they need.

F

To do to be good or outstanding, and they can put all effort into that. But.

F

Actually, it doesn't necessarily translate into good or outstanding care on the.

F

Ground,, so I would hope that we would be,, although we can give some clear.

F

Statements, I would be very cautious about being very explicit in what that looks. Like.

F

The other issue is about the Care Bill, on commissioning.

F

Now, it's been a hot topic for a long while,, and a lot of people want us to.

F

Take back assessing commissioning, my sense from how David presented.

F

That issue was that we would take it if it came our way and we would prepare for.

F

It, I just wondered if we need to have a slightly different stance, that actually, yes,.

F

We do want to take it, because it does have a particular impact on quality, but.

F

Also, the capacity to improve,, because providers sometimes are affected by the.

F

Quality of the commissioning and so are constrained in how they can improve.

F

Now I don't know --, there may be parameters about how or if we take.

F

Commissioning, but I just wondered if, just waiting to see if we are asked to do.

F

It, but making some preparations was a,. The ideal position for us to be.

F

Strategically, or whether we need to make a firmer stance on it.

A

≫≫ Good point, two good points there about making our definitions too.

A

Specific,, then you get into the whole. Well, we hit the target but killed the patient syndrome.

A

So on the commissioning point,, my own view on this, I, don't know if its shared is.

A

That we should be actively seeking to look at the quality of commissioning.

A

From local authorities, does anyone disagree with that?.

A

No, okay. So. That's your point: I think.

E

≫≫ Can I just record that I disagree with that.

A

≫≫ David. Just before you do, John.

B

≫≫ Sorry not to cut across, I'm, not noted for sitting on the fence on this,.

B

So if you look at adult social care commissioning, nationally, my.

B

Calculation is about a third is commissioned by local authorities,.

B

A third is commissioned by CCGs and a third is commissioned by self funders.

B

So, if you really want to have a go at the regulator, contributing to raising the.

B

Standard of commissioning, then my view is, you need to do it across.

B

Commissioning, and not do a partial review of commissioning,, so my only.

B

Point is I think there is some first principles that need to be thought. Through.

B

I was trying to say, Kay, I think this is coming our way, and we'll do it, but we.

B

Ain't got the skills to do what we're being asked to do at the present time, and we.

B

Need to build them in,, so I think there is a pragmatism by what I was trying to.

B

Do and if I didn't quite get the principal bit is let this be evidence based policy.

B

Rather than responding; so we've just looked at what providers have told us.

B

About us and we've said: let's listen to this, but also sift it as well,, but in the.

B

Same way, I think we need to sift what providers are saying about. It's all down.

B

To commissioning, and we need to apply some judgment about whether it's all.

B

About commissioning,, in the way that we do that, rather than saying,,.

B

Yes, that's right,. Let's all do it.

B

Does commissioning have an influence on quality?.

B

You bet your bottom life, it does.

B

Is it the only influence on quality?

B

No, it isn't., Therefore I. Just think we need to be really clear where we're treading in.

B

Relation to this. Also when we see something that is poor, or good, that we're clear what we.

B

Can do about it and at the minute the only thing we can do is shine a light on it.

B

Or use a bully pulpit,, there is no other action. We can take.

B

That's, why I think the policy in relation to this needs to be really worked? Out,.

B

And set out so the board can make a judgment about how we're going to do that.

B

You might as well have been listening to the executive team yesterday on exactly.

B

This point about what the risk of defining everything in such definitive terms that.

B

People, to go back to Louis, play the system and game the system, rather.

B

Than do the right thing,, which is deliver quality.

K

≫≫ I, don't think it is coming our way.

K

I. Don't think local government will have it, I, don't think the DCLG will have it.

K

A compact has been constructed by this government with local government,.

K

Which got rid of the Audit Commission, which is a bigger beast than us.

K

And I think if there is a joint lock on this in the DH and DCLG I, think it won't be coming our way.

A

≫≫ Can, we be quite quick?.

H

≫≫ I was in the middle of my previous point!.

A

≫≫ You'll have to speak faster Louis and I won't interrupt!.

H

≫≫ I won't leave any gaps. This time!.

H

On the report of the provider attitudes,, you said there might be other similar.

H

Reports, I just wondered: who was meant by providers in this situation,.

H

Because, presumably it meant the management of the Trusts primarily?.

H

Because, obviously there are other views within a Trust about the inspection.

H

Process and I'm carrying around with me, I, have a concern about clinicians.

H

And their views of what we do and their scepticism, it just so happened that, after.

H

The -- we had our first wave, by complete chance. I was sitting next to at.

H

An event, somebody,, a senior clinician in one of the Trusts that Mike,.

H

Your team had inspected, and he claimed not to know.

H

Now, he may have just been saying that for my benefit,, but it goes to the heart of.

H

Something broader which is about whether clinicians feel engaged in this.

H

Process and it's essential that they will, I'm sure you have that in mind,.

H

But it's essential that they do.

H

Very quickly, the Mental Health Crisis Concorda,. It's a very important.

H

Document actually, and it's done very well to broaden out what started as a.

H

Concern over the use of police cells for people, as a place of safety for people.

H

Detained by the police under the Mental Health Act,, that is actually one important.

H

But actually quite narrow, issue, I guess a much broader background of problems.

H

In mental health crisis care,, you didn't say that today, CQC has launched an.

H

Online consultation with patients and carers and staff about this very issue,.

H

So that feeding into our thematic review,, so it is becoming a big issue in mental.

H

Health, one of the biggest. And, just one last,. We are guided, of course, in these discussions. By what.

H

David, you choose to highlight, which is very helpful and helps direct the.

H

Comments, but sometimes things are happening off stage in a way or.

H

Somewhere else,, which also need comment, and the last couple of weeks.

H

Have seen quite a bit of activity in Bristol on children's heart, surgery, and now an.

H

Investigation into it is set up by NHS, England, I know, that's not us,, but is it.

H

Possible for us to know what's the process through something like this has happened?.

H

This is, after all, the place that had the previous scandal 10 or 15 years, ago,.

H

What's been our involvement in it,, what should have been our involvement,.

H

Why NHS, England and not CQC; I need to understand what's led to the.

H

Next phrase of the Bristol story.

A

≫≫ On the first point: the clinician engagement, point, I'm, hoping that the.

A

Clinician didn't know what was going on. -- I've met a lot of clinicians who do.

A

Know it's going on, it's interesting to get that observation,. If we don't have.

A

Clinician engagement in our inspections, then we have got an issue there.

A

Mike, what's your observation?.

I

≫≫ My observation is, you can tell me afterwards which hospital it was and I'll.

I

Tell you whether we thought that there was clinical engagement in the whole.

I

Process of running that hospital,, because that is one of the things that we.

I

Are observing, so I, don't think it's just a question about clinical engagement with.

I

Our inspections, I think we undoubtedly observe variations in.

I

Clinical engagement and I can talk more about that at length.

A

≫≫ But just on the point,. This is getting feedback from providers, as distinct from.

A

Clinicians,, can we get feedback from clinicians? That's your main point?.

A

≫≫ Of course we can.

B

The other thing about comparing this again with take my flippancy out about.

B

The date, this was June to August last year,. We were not running any of.

B

These -- Mike hadn't been in the building for more than three weeks when this.

B

Started,, so there is a sense where this paints a picture of what was, rather than what is.

B

But the key issue for this,. Notwithstanding your point, Louis about.

B

What selectivity goes on in the issues I'm raising here, is we're committed to.

B

Making transparent the feedback we got,, having got this independent.

B

Report,, it was appropriate that we publish it and we're seen to draw it to.

B

The board's attention, we'll continue to do it and look at clinical engagement.

B

I'm with Mike,, it probably tells as much about whether the clinician feels.

B

Engaged in the hospital he's working in as ours.

B

The three inspections, I've done I've spoken to clinicians and they definitely.

B

Knew we were there.

A

≫≫ On, your second point,, where there is a story like Bristol;, that's a serious.

A

Issue, where are we in this and where is Bruce Keogh in this, I? Think just a note.

A

To the board, contemporaneous note would be helpful or from you Mike. If.

A

There is a big issue like that, would be helpful.

L

≫≫ It, of course, was in David's weekly issues,, although I think David had.

L

Written that before Bruce Keogh had actually commissioned this report and I.

L

Think that was the disappointing part, that the CQC wasn't asked to.

L

Undertake this new review,, he asked somebody apparently completely.

L

Independent to do it.

L

So I think David does pick up on these things,, but I think that in this particular.

L

Case events have moved on after David had written the issues paper,.

L

Which I think on the whole is an excellent document.

A

≫≫ Mike, on the point about us not doing the investigation, I think the.

A

History here Mike, is that Ian Kennedy,, who is doing the investigation,.

A

Did the original investigation at Bristol, ten years ago.

A

So there was I think a pretty strong logic to get him to go back and look again,.

A

Is that fair, Mike?.

I

≫≫ Yes. Clearly. We have known about the deaths that occurred at Bristol,.

I

We have already looked at a whole range of the issues behind that.

I

I welcome the fact that there is going to be a further detailed review and that Ian.

I

Kennedy is going to do it,, we'll liaise closely with Ian Kennedy on that and.

I

We've already been saying that publicly this morning.

I

I think we also are having a meeting later this week in Bristol with all the.

I

Relevant parties to make sure that we are working together on this, and just to.

I

Reiterate something that Bruce Keogh has said,. He has looked very carefully at.

I

The data on mortality from Bristol and what he is saying about that is that they.

I

Are bang in the middle of the mortality range for children's heart surgery,.

I

For the range of procedures that they undertake,, but we are following that.

I

Very closely and working closely with them.

A

≫≫ Thanks, I think we should move on unless anybody else has a burning.

A

Issue, thank you., Steve?.

M

≫≫ Thank you chair,. The report is for everyone to see, just to briefly come.

M

Back to consistency,, we had a three-hour meeting yesterday morning.

M

With the British Medical Association,, which was looking at consistency as the.

M

Main topic we were talking about and prior to this meeting, this morning,.

M

Another meeting talking about how we build in training and support and quality.

M

Assurance underneath the umbrella of the academy within CQC for all of the.

M

Gps and inspectors, which we'll take on with wave 1 starting in April.,.

M

I'll keep this report. Brief, I just want to focus on the update on the out of hours.

M

Wave 1, which is going to plan,, we've, had to postpone one inspection of an out of.

M

Hours unit because of the flooding in Surrey,, and we felt that adding an.

M

Inspection on top of a very stressful time for all of the clinicians trying to provide.

M

Care would be unreasonable.

M

And, going back to the last board meeting where Paul was extremely helpful about the responses from clinical commissioning groups to our requests.

M

For information, it was covered in the Health Service Journal,, thanks to them,.

M

We now have nine out of the 25 CCGs, who have responded.

M

So, given that our review doesn't just look at the providers of out of hours.

M

Care, but also looks at how that care has been commissioned or whether they.

M

Know what they're commissioning and that relationship,, because that was part.

M

Of my 2010 ministerial review,, nine out of 25 is still not good in the time they've.

M

Had, but at least it's better than nothing, and we'll be reporting in April as a first.

M

Report,, but the reviews of out of hours continue right. The way up, till Christmas.

M

We're, making good progress, we've had training sessions, we've got at least.

M

Eight half days and days of quality assurance and consistency, meetings,.

M

Because we're learning from this on how we apply wave 1 to in hours as well, thank you.

A

≫≫ Any questions for Steve? Kay.

F

≫≫ On the developing the new approach to inspecting primary care,.

F

Are you involving and collaborating with patients, patient groups in developing that?.

F

For example: I know there are some Local Healthwatch, for example, that have.

F

Done work in GPs or for GPs, in terms of co-production,, is it also with patients.

F

And the public?.

M

≫≫ There are two aspects to that: really, right. The way from the start, we've said.

M

That using patients, the public and making sure we reach out to groups.

M

Which health services don't tend to reach out to, the homeless,.

M

And particularly minority ethnic groups, too, is going to be important,.

M

But collectively across the three inspection directorates, we've agreed.

M

That Chris Day in Paul's team is doing a review of experts by experience and how.

M

We consult and work with the public, because for me it's not just about.

M

General, medical practice,: it's about the integration and feedback,.

M

So the answer to the question is we're doing a review of that led by Paul's team.

M

As we start to work forward. Looking at in hours,, then input from those groups into.

M

Ratings, into how we do our work is absolutely essential, and, as you'll be.

M

Aware, with another hat on,, my last role, we're just completing a review of.

M

Transgender healthcare across England and we've been very keen to work with.

M

That community,, who often have poor access and variable access to.

M

Healthcare, just to see how we can improve what we're doing and the questions we ask.

M

The last four months has been set up mode and we're just starting to get now.

M

A team to do work on what you're suggesting.

F

≫≫ Just worried that we might miss the boat in terms of patient and public.

F

Engagement in the set up, phase.

M

≫≫ Thank, you, I'm sure you won't, let me miss the boat and it is absolutely.

M

Core to everything, we're doing.

J

≫≫ Just on Kay's point and then more generally, on Chris, Day's, review, I. Think.

J

It's fair to say now that Healthwatch England are locked into the groups that.

J

Are helping to develop the inspection regimes and we've obviously got a very.

J

Clear eye on how Local Healthwatch will play into those, I think it's fair to say,.

J

I, don't know what Mike would say, but I think in relation to the hospital.

J

Inspections, it's been a kind of mixed picture at both ends,, both in terms of.

J

Local Healthwatch's ability to engage and actually for the inspection teams, to,.

J

And the whole process to remember to engage them, so learning as we go,.

J

But that makes it really important that we retain an eye on how that will all work.

J

Across all three inspection, regimes.

J

Just before you take the mic, Steve, on the Chris Day engagement, review,.

J

I think it's really important. -- I've talked on a number of occasions about the fact.

J

That I think there is a need to reflect on the way that we involve and engage the.

J

Public, generally, actually at the CQC,, but particularly in the context of the new.

J

Inspection regimes,, so I'm really glad that the review has been commissioned.

J

But I would be really interested to see the scope and nature of that review.

J

I think experts by experience are a tremendous and very well understood.

J

Success of the past,, but they are not the be all and end all of the way that we.

J

Should engage and involve the public, and so I think there's a kind of much.

J

More expansive review that we need to do and to do that well, at CQC. We need.

J

To engage with a range of people who have done a lot of work in this area and.

J

Make sure we draw on that experience and learn from it.

J

So I really appreciate sight of that and I guess for Healthwatch England in.

J

Particular to be closely involved in it,, but I think for the board to have sight of the.

J

Scope of the review would be a good thing.

C

≫≫ I know Chris will be very happy to know that there is a Day review,.

C

It's more that it's his day, job without making a pun,. So as director of.

C

Engagement, so, firstly, the experts by experience, piece of work is absolutely.

C

Anna, as you say, set in the context of all the different ways that we need to.

C

Engage with the public and people who provide services, and although experts by.

C

Experience is one element of it, it is only one element,, so Chris' job is to solve.

C

That and I'll make sure you get a briefing on where that is up to overall.

C

The specific piece of work that Steve was alluding to,, as we have a series of.

C

Contracts coming to an end with different providers of our experts by.

C

Experience programme, we're looking at whether we're making the right decisions for the future in our new approach, in the way that we procure.

C

That and frankly, whether it's important enough aspect of our work,.

C

Whether it's something we should be fully outsourcing or bringing more.

C

In-House,, that's the big piece of work to be done.

J

≫≫ Can I just come back on that just for a second,, so that is very clear and.

J

Reminds me that we had a conversation previously about the potential increased.

J

Demand for experts by experience and how we manage that,, which I understand and I know we need to do.

J

I, would like to us, do a review of how we engage and involve the public in.

J

Our inspection regimes and more widely- and it is probably a separate exercise,.

J

How we do this in CQC,, so if this isn't a Day review,, can we please think about.

J

How we might do such a thing in due course,, because I think it is required.

K

≫≫ This is just specifically around patients and out of hours, services,.

K

Because the, without pushing the point,, if the CQC's don't know who is providing.

K

The service,, it's pretty likely the public don't.

K

And, actually, the failure of this service is causing one of the biggest crisis in the.

K

National health service in terms of emergency, admissions,, etcetera,.

K

So it's quite difficult because actually we need to engage with the public about.

K

Their non-engagement, the questions around who do you phone,, does such a.

K

Service exist,, those sort of things and I think we'll find that for lots of people, the.

K

Service doesn't exist, and that's probably one of the most important findings,.

K

So how you find that,, it's engaging about non-engagement.

M

≫≫ On that specifically we're pretty sure we know who is providing the service.

M

There are some instances which we'll get to, where GPs have elected to do.

M

Their own out of hours, who are then asking others as a subcontract to.

M

Provide the care. What we're doing as part of this review is making sure we are absolutely certain.

M

On our database,, because coming into this with a history; I've got unfinished.

M

Business on out of hours,, because I think it's an area of risk and we're.

M

Making progress,, but it's disappointing when we asked for information it doesn't.

M

Come back quickly and that's a learning point for all of us: I think.

M

I think Anna is absolutely right on the work, we're working very closely with.

M

Paul's team led by Chris and I'm learning as well,, in that my original.

M

Thoughts for how we engage with the public as we've spoken about before,.

M

Were based on the new primary care model of going into each CCG, every six.

M

Months and having a presence, the more we learn, particularly from Mike's.

M

Experience of hospital visits, how they engage with users of hospitals,.

M

It's becoming more obvious that the drive will be in localities,, so that you'll be.

M

Able to build up over a rolling time, information from local users of the.

M

Service and the public, of which Healthwatch has a really crucial role,.

M

That also means it will have a knock-on effect for how you consult on a service.

M

And how actually we timetable our GP inspections, so that we start to integrate.

M

Them more with looking at local care services, as well as hospital and mental.

M

Health, and so as we start to build our team and look at this, we actually are.

M

Working very, very closely with Chris Day and his team on how that evolves,.

M

And we've not done very well with engaging the public in out of hours,.

M

Because if you advertise even on local radio,, please come and talk about your.

M

Local GP out of hours service, in Birmingham, we had zero people turn up.

M

To an event that we held,, despite local publicity, and in Bristol, there were fewer.

M

Members of the public there than they were members of the CQC.

M

I say that because I want to be open and transparent and look at the different.

M

Ways of engaging,, of which we have to do better, and when you talk to the.

M

Public about out of hours, services, those who haven't used, it don't know.

M

What we're talking about quite often, those who have used it, find it very.

M

Difficult to access them, at the moment, with 111 or ringing a GP and getting an.

M

Answer phone, there is still inconsistencies,, but all of these things.

M

We're finding highlight the importance of the review, we're leading on and I would.

M

Anticipate that in May,, hopefully April but May board meeting we'll be able to.

M

Share some of our findings.

K

≫≫ Makes, my point,, the NHS are providing services for 50 million people.

K

That nobody seems to know about.

K

Which actually seems to be a real problem and you're quite right,.

K

Engaging with people that don't know about a service is not likely to happen.

K

But, it still is a really crucial issue,, because people don't know about it,.

K

They go to A&E.

M

≫≫ My final point: chair, I did promise, you I'd be brief,, and this is brief for me!.

M

M

Is I had a very good discussion with Cliff Mann,, the president of the A&E.

M

Doctors, emergency medicine, doctors, I'm, just looking at how we can.

M

Engage more, I think the model needs to evolve to how we look at urgent.

M

Care in areas rather than just one particular part of it, and what I'm looking.

M

At is how we get regularly feedback from the emergency departments on out of.

M

Hours services, because we know in two parts of the country from local GPs, they.

M

Are telling us that in almost identical rural areas, the A&E attendances are.

M

Higher in one area compared with one just up the road, because there are more.

M

Doctor triage and contact with the patients who ring for advice than in the area just south.

M

And I think we'll find some really interesting things beyond what I thought.

M

About before,, but also, if you go back to the ministerial review, I still want to.

M

Satisfy myself that the performance list is working,, that providers are.

M

Interviewing doctors working in the services, and they have methods of.

M

Quality assurance and until I'm satisfied with that I won't be.

G

≫≫ Very briefly I'm becoming concerned about GPs charging for care home visits.

G

Cqc did a report on it a few years ago and thought 10 percent of GPs did that.

G

And the Sunday Times is actually looking at that and discovering that it's.

G

Probably more, I wondered where that was going to sit,. It seems to me pretty.

G

Iniquitous, GPs are still paid per capita and still getting the money, and I think.

G

There is quite a lot, I. Just worry that there is an issue. There, I wondered where that.

G

Would fall across our various departments?.

M

≫≫ Thank you very much. It falls very well with all of us in here actually, and we are just in the middle of.

M

Correspondence with Ministers who raised this issue with us.

M

And the answer to the question in a legal terms: are, general practitioners, like.

M

Myself cannot charge for GMS services,, but within the regulations,.

M

I can't remember the Section 5 says you can, above and beyond that.

M

What disturbs me more than the regulations in a way,, because I can see.

M

The need for many local area teams are talking about local enhanced services.

M

For providing extra care to care homes, in some areas, the care, homes and.

M

Nursing homes provide what were hospital care above and beyond. Gms,.

M

I am disturbed by some of the newspaper reports about GPs, refusing.

M

To take on patients from some care homes, unless they get a fee.

M

That is completely wrong.

M

And, we'll look into that when we start to do our inspections, and are already.

M

Trying to pick that up in, before we move to the new model, I share your concerns.

F

≫≫ Just to add,, because it is a shared responsibility between Steve and I,.

F

Around this, and Care England,, the trade association for some of the larger.

F

Providers, released information earlier this year,, which was really highlighting.

F

And may well have piqued the interest of the Sunday Times as well around this.

F

And Steve and I are working with each other to respond also to Care England,.

F

And to pick up on the good practice guide that Social Care Institute for.

F

Excellence has recently produced which actually enables care homes to have a.

F

Firm basis for some of their discussions about what support is actually.

F

Appropriate in the care homes,, so we're trying to deal with this on various fronts: Camilla.

F

Leading neatly on, thank you.

F

You've got the report and to be quick as we're running past time. Now,.

F

I'll just highlight a few things. The first is just to reassure Kay that we are indeed co-producing with as many.

F

People as I can possibly talk to in the development of the new approach,.

F

And the policy team sitting with Paul and led by Rachel Dodgeson has been.

F

Absolutely fantastic in working with me on that,, but one of the things we are.

F

Thinking about is how we use that information from people, from the.

F

Public, people who are using services, families and carers, as part of the.

F

Intelligent monitoring for adult social care, that obviously includes linking up.

F

With Local Healthwatches as well.

F

And so one of the things that we're exploring with the "think local act.

F

Personal" sector led improvement. Partnership is how we can link with the.

F

Work that they are doing on building community capacity to look at how we.

F

Make all of those dots link, so that we're making the best use of some of that.

F

More qualitative information that can help us to understand what's happening.

F

In the social care sector.

F

The second thing I wanted to highlight was the wave 1 inspections for adult.

F

Social care, because there's a lot of activity going on with that at the.

F

Moment, we're in regular correspondence and liaison now with.

F

The services that will be included in the first wave, both identifying those and.

F

Also working with them to get some information back from them, so that for.

F

Example, in the community services, we can actually proactively go out and seek.

F

Views from people using services, but also healthcare professionals and.

F

Others who may have views on those services to feed into the inspections.

F

Before we go, so there's a lot of activity going on there, we've identified.

F

Inspectors who will work with us on that first wave,, so that we can really focus.

F

On the learning that we need to do in testing our approach,.

F

Once we start on the 1st of April.

F

And that will feed into the evaluation that we do of that, and again teams in Paul's.

F

Section, Christina Cromwell is helping us with this to look at the questions that.

F

We need to ask, both of providers,, but also of our own inspectors, in terms of how that goes.

F

We know that we are going to be learning and our volumes kind of give us.

F

A real challenge around consistency, as everybody has spoken, about, and so.

F

Although we'll be looking at how we would rate a service,, we'll not be.

F

Publishing ratings for that first group,, because I think it could be misleading.

F

For the public and people using services and potentially unfair for providers when.

F

We really cannot be guaranteed of the robustness there,, but we'll use that learning.

F

David's obviously already stolen my thunder around the announcements of.

F

The new deputy chief inspectors,, but I'm delighted we have made such a strong.

F

Set of appointments and really looking forward to working with them and would.

F

Just like to record that. Thank you.

A

≫≫ Any questions for Andrea?.

H

≫≫ Andrea, can you just say a word about Winterbourne View?

H

The CQC sponsored a meeting last week about the progress under.

H

Winterbourne View,, it was an absolutely unforgettable meeting actually,, which I.

H

Sort of chaired after a fashion,, but in fact the leading performances were the.

H

Families who came to,, who weren't specifically from Winterbourne View,.

H

Although one was, who came to talk about the experience of failures in the.

H

Care of their family members,, who had learning disability and who were in institutional care.

H

The ramifications are very broad, about the mental care system,.

H

The Mental Health Act, standards of doctors doing the assessments,.

H

So many issues that these cases raised, that it's just very important: that we don't.

H

Lose sight of this as a body of work, and I just wanted to get your view on where.

H

The next,, what the next step might be on it?.

F

≫≫ Thank you. Mindful of the fact that Winterbourne View was indeed a hospital and an.

F

Independent hospital and actually in terms of the inspection regime, sits with.

F

Mike,, but in terms of the issues to do with regulating, inspecting services for.

F

People with learning disabilities,, that's a shared responsibility between both of us.

F

Supported by the policy team sitting with Paul, and I, think that the thing that Mike.

F

And I are absolutely at one with each other. On, is that we learned the lessons from this.

F

We learn the lessons from Winterbourne View in terms of what.

F

Happened there and how CQC responded to that and what we need to.

F

Do in terms of our inspection and regulation regimes,, but equally we listen.

F

To the voices and we take to heart,, if you like,, I, absolutely do,, take to heart the.

F

Experiences of those people who have used those services or had loved ones.

F

In those services and have been failed by them.

F

In terms of the specific event, I've spoken to Alan Rosenbach, who helped.

F

To organise that and I've met with -- Mike and I met with Viv from the.

F

Challenging Behaviour, Foundation and I also met with one of the women who.

F

Talked about her story of her son at your meeting last week, and I. Think that, as in.

F

Any of these things, it's actually hearing those personal stories that really remind.

F

Us why we do what we do and why we need to do it as well.

F

So we'll continue to work, with, and I know that there is going to a write up of.

F

The day in terms of the issues that were raised, I previously had spoken to Sarah.

F

And had identified some specific issues she raised with me that we need to feed.

F

Into the methodology that we've got, as to how we ask questions and the things.

F

That we should be looking at; I know, Mike's got some very specific issues.

F

That he's going to address in terms of how we look at the services that are.

F

Provided for people with learning disabilities across all of our sectors,.

F

Including hospitals,, so you can be absolutely guaranteed that a one-off.

F

Event is not going to be such.

A

≫≫ What was your impression of it Louis,. What did you take away from that? Meeting?.

H

≫≫ Well I took away a concern --. First of all, the people there who were.

H

Presenting the stories of their families had yet to be convinced that the system.

H

Would change, that wasn't particularly directed at CQC,, although they had.

H

Some criticisms of CQC,, they clearly felt that the fundamental change in.

H

The provision for people with learning disability, they hadn't seen it.

H

I suppose my concern was there were so many elements to what went wrong...

H

...Which has to be remedied by Mental Health Act code of practice,, but also by.

H

The professional standards of psychiatrists and who is determining that,, because somebody was resectioning, redetaining these.

H

Individuals and therefore, presumably approving their care plans without -- and.

H

These were unapprovable care plans,, yet they were being approved.

H

So, it was partly about the question of residential care versus community.

H

Provision for people with complex needs,, that's at the heart of it,, which is why I.

H

Asked you about it,, but there are these other elements,, all of which adds up to a.

H

Package of transformation,, unless we get all of that right, we'll not win the.

H

Confidence of the people who have been affected by it.

F

≫≫ If I may David, I think that CQC has a role to play, and we are committed to.

F

Playing that role,, but it's a role to play in a system, and actually working with.

F

Others is absolutely critical with this, one of the things that's happened very.

F

Recently is the joint improvement programme which was established after.

F

Winterbourne View, has just gone through a change of leadership and Bill.

F

Mumford has now been appointed as the director and one of the things that I.

F

Think that we do need to do to work with him as well as working; and Louis.

F

Is absolutely right,? Some of the professional aspects of this go to the.

F

Heart of what do mental health professionals do sometimes,. We have to.

F

Work across the system with those other people, to make sure that every lever.

F

That we possibly can pull is pulled to actually make the difference,.

F

Which I've sat down and listened to some of those stories and frankly, they.

F

Make me cry,, because it just is not what should be happening.

F

Not in this day and age.

F

And, we need to make sure that we make those connections and we push.

F

From the side as hard as we can.

H

≫≫ You asked my impression.

H

One unforgettable part of the impression that day left was what happens when.

H

The system hasn't got the right provision for you, and what happened to some of.

H

The people is that they ended up in a place which was unsuitable, I, don't just.

H

Mean Winterbourne View here,, it's more than that,. They ended up in a place. That's.

H

Unsuitable and then because that place doesn't suit their needs, they end up.

H

Behaving in a way which confirms to everybody that their needs are greater.

H

Than they thought and therefore they become more embedded in a system.

H

Which was wrong from the start.

H

And. The first question was whether or not they are being properly placed or.

H

Properly provided for,, whether their needs have been understood,, one of the.

H

Most impressive stories was when somebody was taken out of effectively.

H

The wrong residential care system and was now living independently in the.

H

Community, and honestly, you felt like cheering at the end of that,. It was such.

H

A powerful narrative about somebody, that at every stage, the incorrect.

H

Provision was being compounded by the reaction of everybody saying there. You.

H

Are you see,? We knew that she was a person who wasn't going to cope in this.

H

Environment,, we need to do even more to restrict her and contain her,.

H

Actually, what she needed was to be somewhere else., That element, I, think, I- think we do --. This is part of the problem,. A lot of people are.

H

Responsible for putting this system right,, but we have a leadership role.

B

≫≫ This is the point that I want to make, I do think we have a role to say this is.

B

The wrong model of care. I thought we were closing down: hospitals for people with learning disabilities, not opening them up. This plays to the commissioning point,. Why were these commissioned and by.

B

Whom and why, your point about professionals Louis is spot on,. That's.

B

Been one of the quiet things in the narrative about Winterbourne View,.

B

There has been a lot because CQC came out and publicly apologised from.

B

The beginning, it got it wrong and there has been a deafening silence from.

B

Others about what their role in that has got to be in my view.

B

But I think this plays to the earlier conversation about how we engage with.

B

The public and the public that we can't engage with,, but this is absolutely the.

B

Reason why we should be listening to the voice of people using services,.

B

One of the things we've been doing over the past 12 months, in particular, is really.

B

Exposing ourselves by holding those events, I, hold monthly leadership.

B

Events, we've just completed our second major conference, where we had.

B

300 people together, and we are pretty determined not to have any of those.

B

Events without having the voice of people using services beginning or.

B

Making a contribution to that day, because it's a leveler in terms of.

B

Reminding people why we're here., So I think there is a bit about building in, Paul uses the word rhythm of our.

B

Organisation, I think we should build into our organisation a rhythm which doesn't.

B

Allow us to do some of these big set-pieces without having the voice of.

B

People who use services, or their carers in the room.

B

Because, it plays to the point about how we know what users and carers are thinking of, us,, how we know what our stakeholders are. Thinking of us.

B

I think the Care Bill does give us, in terms of fit people and the changes to.

B

Our registration responsibilities in my view, it gives us the ability to say I, don't.

B

Think this is a good service,. We should not be registering it because it's not meeting needs.

B

Now that will take us into an area where people will be really uncomfortable,.

B

But who gave planning permission to a care home on the intersection of a.

B

Motorway on an industrial estate?.

B

So I think we need to trace it back about how do these things get.

B

Commissioned, built, funded,: why are they continuing to be used, who keeps.

B

Reinforcing them, and the bit of the system that we can influence is that bit.

B

About why did we register it,? Why did we think it was a good model of care that.

B

We thought we could register a hospital,, so I think your challenge as a board to.

B

Us has got to be about what are we registering and why,? That's one way we.

B

Can get at our leadership responsibility and sometimes we are going to have to.

B

Say I'm, sorry, we don't think it's good,. Yes, you have all the finance in place,.

B

Yes, that's a good registered manager,. Yes, you have all those things, but we're.

B

Not convinced this is the right model of care, and then that will be a fascinating.

B

Discussion, but ultimately that's what we need to do, so you're, absolutely right to.

B

Challenge us,, but we must keep listening.

F

≫≫ Very quickly,, these services that are commissioned are extremely expensive,.

F

And actually, there needs to be some courage somewhere to have a very clear.

F

Plan to redistribute this money into the proper services,, often in the community,.

F

Because they are so expensive and yet they're not delivering outcomes. And we.

F

Need to be careful that we don't continue to perpetuate that model,, but also to.

F

Engage more widely, because it does require some courage to take money out.

F

Of these services that don't really deliver, to try to get them into where the money.

F

Can actually be more effective and useful to people.

A

≫≫ We haven't got time to do full justice to this, I'm glad you raised the issue,.

A

Could you circulate the notes of the meeting that Louis referred to, to the.

A

Board, if they would like to see that.

F

≫≫ Yes I'll follow that up with Alan.

A

≫≫ Can, we come back to this, David, in a month or two's time?.

A

I'm left with, there's a big issue: here, sort of hanging there, we're sort of.

A

Responsible for it, but what's happening?.

A

Can we come back to it when we have more time?.

B

≫≫ We can, and what we'll try and do is map out what the other contributions are.

B

Norman Lamb is chairing a group, which is looking at what the commissioners are doing, what others are doing and what we need to do as our contribution.

B

To that, so we'll try and bring a report which actually goes through it.

A

≫≫ Okay, Mike. Thank, you Andrea.

A

≫≫ Thank you very much, I'll, just give quite a quick report, things are moving.

I

Apace in the hospital sector, for wave 1, which everybody knows we had 18.

I

Trusts in that wave, that's completed before Christmas and the reports are.

I

Now all completed as well, the whole issue about consistency and getting the.

I

Right, well partly about getting the right teams, but about the consistency of.

I

Reporting are very live in our minds and we are reviewing the whole of that wave.

I

At the moment, and we are planning to publish an overview report in due.

I

Course,, hopefully in March.

I

Since, then we have moved on to wave 2 and there are 19 Trusts in -- Acute.

I

Trusts in wave 2,, nine of those have now been inspected,, but none of the.

I

Reports have yet come through,. That means that we have done a total of 27.

I

Of 161 Trusts in the country,, which actually means we've done one in six of.

I

All Trusts in the country, we have at least inspected them.

I

And, the new ones that we have been to are Leicester, Blackpool,, North.

I

Hampton, Royal Cornwall, Hull,, Morecambe, Bay, Homerton,.

I

St. Georges and Heatherwood and Wrexham Park.

I

In wave 2, we have incorporated changes and lessons learned from wave.

I

1,, for example, we now have a conversion programme for our own.

I

Cqc inspectors,, so that they are getting trained in the new approach and over.

I

100 inspectors have been through that programme, I'm sure there will be need.

I

For more training,, but that is at least a start.

I

With Paul's team. We have been working very hard on the question of what good.

I

Looks like, and the guidance that we can give to providers on that, and also.

I

Obviously, to our own inspection, teams.

I

We've juggled around the time we use onsite to a degree,, so the chief.

I

Executives of the Trust we're providing give us a presentation on what we call.

I

Day, nought, the training day, so we get a flavour of what's going on in the Trust.

I

From their perspective, before we go and look for ourselves- and we also hold the.

I

Listening event with the public and patients on that, the evening of day.

I

Nought so that can inform the whole of our inspection.

I

We've tended to bring the focus groups with staff forward in the inspection and.

I

The interviews with management put them later in the inspection,, because.

I

Focus groups are effectively data gathering sessions, the interviews we.

I

Can then challenge back to the trust with what we have seen and what we have heard.

I

And another change for me is that, after these inspections, our new heads.

I

Of inspection are sending me very soon after the inspections, at least their.

I

Headline views of what they have found at the Trust,, that gives me an.

I

Impression of what's going on there,, because obviously at this stage it's no.

I

Longer possible for me to go to each of the inspections myself.

I

But I do get a very good flavour from those immediate responses.

I

Going beyond the acute hospitals, I'm, very pleased to say the mental health.

I

And community service inspections are now underway,. They are wave 1.

I

We have now done four pilot. Inspections, two are for community.

I

Services, two for mental health,: they are Central Essex, which is a social.

I

Enterprise,. Community health, service,, Coventry and Warwickshire, which is.

I

Mental health, Bridgewater, which is community services and Devon.

I

Partnership,, which is mental health. In addition to that one of the acutes that we've done on this wave is.

I

St. George's,, which also has some community services involved. So that's a.

I

Combined, look at acute and community.

I

I think what we can say at this stage is that the broad approach we developed.

I

For acute inspections can be applied and adapted both to mental health and.

I

To community services,, clearly there are differences,, there are differences in the.

I

Actual services we're looking at,, there are differences in the travel required,.

I

Louis will be very well aware the size of the mental health Trusts and.

I

Geographical patches, they cover,, so we are not only looking at the in-patient.

I

Services, but we are travelling around to look, for example, at crisis teams in.

I

Different parts of the patch that they cover and the same on the community.

I

Services, visiting not only where district nursing teams are based,, but actually.

I

Going out with the district nursing teams and seeing how they do their work,.

I

And we are also speaking to patients who've recently been under the care of.

I

Community services to get their views on care, and this wave of mental health and.

I

Community services we're now just about halfway through it,.

I

That will conclude before Easter and I would again hope we can publish some.

I

Form of overview report,, probably by about May.

I

Just, finally, to say two of my deputy chief inspectors have now started,.

I

Andrew Gordon and Paul Lelliott and that's extremely welcome and the other.

I

Two have been announced and Ted Baker will start in the middle of March.

I

And Ellen Armistead in the beginning of April,, that will also be very welcome.

A

≫≫ Thanks Mike, Michael we've heard three reports from chief inspectors, any observations?.

L

≫≫ I think they are three excellent reports.

L

I think the question that I think in a way runs through all of them is, and it was.

L

Touched on when we discussed the...

L

Admittedly, pre-new regime research into what providers think about the CQC,.

L

Is this question of standards,, and especially, is the CQC setting minimum.

L

Standards and are the standards it sets if they are minimum standards, high enough?.

L

I think is a sort of consistent, theme, and I think it is something which the CQC,.

L

I'm sure the executives are concerned about this.

L

In the CQC's definition of purpose, it does say high quality care,, and yet there.

L

Are clearly some provider who is think that the CQC is inspecting for.

L

Basic standards of care,- and this applies across all the three directorates.

L

I think getting a strong understanding within the CQC and outside the CQC of.

L

What we mean by high quality, care, I, think is very important,, as I say in a way.

L

There is a consistent theme across the three reports,, even though they've been.

L

Focused on the individual areas.

A

≫≫ Any other comments on Mike's report in particular?.

A

That people would like to pick up?

A

A

Thank. You Mike, we're coming to you much more in the private session actually.

A

C

≫≫ So: this is the Q3 corporate performance report, and it's a twin paper.

C

If you like, with the complaints report, which Eileen will present.

C

In the interests of speed,, if I just point to the pages, 1 and 2 in terms of the overall.

C

Highlights, rather than going through each of those bullets and similarly on.

C

The areas for improvement,, but if I just pick out one or two.

C

It's worth saying, our enforcement activity has significantly increased in Q3.

C

Compared to Q2, so 410 cases of enforcement rather than 353, similarly,.

C

Up on Q1, and that highlights some of the Board's earlier discussions about the.

C

Need to look at this area, and it moves onto the other issue. You'll see picked up.

C

Around people who have been non-compliant for over a year and a.

C

Number of actions that we've taken against that,, the first thing to say on the.

C

Numbers, the numbers haven't decreased in the last quarter in terms of.

C

Those who have been non-compliant for over a year,, that's why we're particularly.

C

Targeting our resources on those,, we have issued 136, fixed penalty notices.

C

For providers who haven't had a registered manager for over a year,.

C

And although that's a difficult message for providers, there is good evidence that.

C

That's increasing the number of registered managers in services, which we know particularly in care homes, is linked to high quality care.

C

We also have good evidence from the providers survey. That providers are.

C

Increasingly, confident in the work we're doing, which is a positive sign and plays.

C

To some of the discussions we had earlier on, the research work.

C

If I just turn briefly to the finances,. These are very similar to what you've.

C

Seen before, there is a slight predicted underspend on the revenue side and a.

C

Significant underspend relative to the beginning year, budget on the capital.

C

Side, but I think the two points to say there is we always set out in the capital.

C

Budget, a potential maxima and given the amount of design that we have been.

C

Doing over the year, I think it's probably inevitable that not all of the capital is.

C

Going to be spent, if there are things that we see, isn't necessary, or where.

C

Our design leads us to believe we need to think more carefully about what the.

C

Capital spend will be, it's better. We don't spend the money and spend it more.

C

Effectively in another year than rush to spend the full budget, because we said.

C

That's the maximum figure in the first place.

E

≫≫ Not so much a question, I just wanted to flag up the depressing data of.

E

The inspections carried out so far, this year, we're still running at about 20.

E

Percent non-compliance, level,, which is the historic level at which we regularly.

E

Found non-compliance,, so there are still a significant body of providers out there.

E

Who are not on the, when they are inspected, achieving standards,, whether.

E

They regard them as basic or anything else, that we expect to see, I, think --.

E

These are people who will have been inspected at least once already,, so every.

E

Time it goes around, there still seems to be a significant base, core of providers.

E

Who are not achieving the requisite standards under the old system, and the.

E

Other depressing feature really is the extent to which providers who are.

E

Non-Compliant, there is still a core of them non-compliant after a year and.

E

That is not improving either, I'm, not blaming anyone around the table,.

E

I'm just saying these are depressing features about the population of.

E

Providers that we're inspecting.

K

≫≫ I think, if we're going to have a new form of inspection, we need.

K

A new relationship with compliance,, otherwise all we're doing, is a really.

K

Better form of finding out what's wrong.

K

And, so there needs to be --. We need some way of acting on non-compliance.

K

Quicker,, so if 20 percent of people are non-compliant after a year and that.

K

Continues in two years time, when we're doing wonderful inspections and finding.

K

Out things are wrong, that will be failure.

A

≫≫ Paul: do you think having ratings will of itself be a bigger incentive for people.

A

Who are not compliant at the moment to improve?.

K

≫≫ I think those people that have got the wherewithal to improve will worry.

K

About the ratings and probably improve because of them, those people that have.

K

Not got the wherewithal to improve won't, and that may be 17 percent,.

K

And so in a sense, what is the --? What do we do within a year?.

K

Because a year is quite a long time for these, for organisations to be.

K

Non-Compliant, so I just --. This is just another general discussion. Around,.

K

It would be rather a shame if we end up with three brilliant sets of inspections.

K

That, then, don't impinge on 20 percent of the care in the country.

F

≫≫ I think that's a really good point.

F

I know. We've said that we encourage improvement, because obviously.

F

Improvement rests with very many people and ultimately, it's up to the.

F

Providers to improve, but I have said this quite a lot,, but I think we need some.

F

Clear improvement model which clearly defines our role and others,. Because at.

F

The moment it's not that clear, I'm, aware of various things that can happen within.

F

Cqc and without CQC, and there's the failure regime and all sorts of things,.

F

There's the TDA and Monitor,, and certainly from where I'm sitting it's a bit.

F

Confused and also if you do get an improvement, you can get an.

F

Improvement too quickly,, so it's not sustained,. So it's not a straightforward.

F

Issue, but I just feel that we need to be able to define it more tightly,.

F

Both what our role is and -- yeah, it seems,. It's not clear enough at the.

F

Moment,, but at the same time we have to be quite clear what our role is and what others is.

A

≫≫ Our role is pretty clear,. We are not an improvement agency,. We are there to.

A

Shine the light on what is happening and the improvement has to be done by the.

A

Provider and if they can't do it, then it goes into the failure. Regime.

A

J

≫≫ So I want to pick up on this point as well, I guess I'd observe that we did.

J

Have some really important dicussions about the register? Manager's question a.

J

While ago and decided to take a stronger approach,, which clearly seems to have.

J

Brought some dividends in terms of the numbers of non-compliance in social.

J

Care organisations over the last period, I, don't know how much of the registered.

J

Manager issue can take the benefit,, but it seems to me that -- so I'm really.

J

Glad that the executives are going to look at this over the next period,.

J

Because I think in the other sense it's going the wrong way and I think the.

J

Points Paul makes are really key.

J

I'd just like to ask that we have, at an appropriate meeting and not too far,.

J

Away, a report from the executive on what you've learned by looking at these.

J

About what the residual issues are and how many of these we can.

J

Address by taking collective actions on some themes, which may repeat across.

J

These non-compliances and what the plan is for addressing them.

J

So I take Kay's point about improvement, but from the public's point of view, what I.

J

Want to be able to say is that, where there's something which is.

J

Non-Compliant and by that I would read, therefore unacceptable. As far as the.

J

Public are concerned, that if they don't get it right, they no longer deliver that.

J

Service,, which does take them to the failure regime place and actually that's.

J

The harsh reality, but the one the public need to know we're supporting by.

J

Addressing these figures.

A

≫≫ Just picking up on both those points, can we bring back to a meeting later,.

A

Because I think enforcement is something I'm, not probably as clear in.

A

My mind as I ought to be,. Maybe we can have a paper in a couple of months time.

A

Which picks up both Kay's point and Anna's point.

B

≫≫ I think that would be a good idea and I think we should segment it as well,.

B

One of the debates yesterday is it two inadequates and you're out?.

B

So there are some really important issues provoked by not just this historic.

B

Data of what we're doing under the current model and Paul as ever, I think.

B

It's absolutely the right challenge to us,. There is no point in having the most.

B

Elegant well supported methodology that doesn't make a difference and it plays to.

B

A paper that's later in our agenda on evaluation,. How do we know it's making.

B

A difference and what is the difference? We're making?

B

So? We have taken fixed penalty notices,, but also we've seen a rocket in the.

B

Acceleration of applications for registered managers,, so the deterrent.

B

Effect of doing something,, we need to capture not just the action that we are.

B

Taking, and what the outcome of that is,, but there's a clear signal that people are.

B

Behaving differently, as a consequence of us saying this is what we're going to do.

A

≫≫ Paul did you want to respond to that before Louis?.

C

≫≫ I wanted to position that we're committed as an organisation an.

C

Updated enforcement policy in June/July time,. This is largely in response to the.

C

Changes in the regulations going through following the Care Bill,.

C

We need to look long and hard anyway at our enforcement policy, just from the.

C

Point of view of that legal requirement,, but the opportunity to go sector by.

C

Sector, build on the work already done with the NHS Trusts in terms of the.

C

Single failure, regime and special measures and work out what we're going to do. Equivalently in adult social care and primary medical services.

C

Where the improvement bodies are completely different.

H

≫≫ That almost covered what I was going to ask. About, I was struck by the.

H

Pie chart on page 8 about enforcement and compliance reports where the.

H

Number of enforcement actions; I think this is a cumulative total for the current.

H

Year,, if I understood correctly, and the numbers in different sectors go 5, 16,,.

H

21 and then they go to 990!.

H

And, that's in adult social care, presumably, I. Suppose there is a slight.

H

Sense here of a book where the final chapter has been ripped out,, what then happened?.

H

And also, what were these 990?

H

Because? It's such a big number that it asks a question about what is the detail.

H

That lies behind that?, You could say some of the sectors in that pie chart maybe need a little bit of.

H

Desegregation as well,, because the NHS is one of those sectors and you might.

H

Want to know a bit more about how the NHS breaks down according to these,.

H

But it's really --. The issue is the one you were just touching on,. What then.

H

Happens and what is the story that we then can tell, accepting we're not.

H

Necessarily responsible for the improvement itself.

A

≫≫ It's obvious, isn't it? Yes.

A

A

Right thank you., Eileen you're, doing a report on complaints?.

D

≫≫ Yes indeed. Thank, you.

D

Obviously. You have the paper in front of you, in the interests of brevity I'll take.

D

Any questions,, but a few highlights and themes I'd like to draw out,.

D

And it's fundamentally around highlighting that there has been much.

D

Progress in terms of understanding how important complaints are to us and really.

D

Focusing on how we manage that function through and manage it, well,.

D

But clearly much remains to be done and to give you a flavour of what is.

D

Being done that I think might be helpful,, so we are doing a great deal of work on.

D

Actually, ensuring that complaints and concerns that come to us are,.

D

Have a smooth passage through to the appropriate place for them to be dealt.

D

With and that's actually a very important thing for us to make sure things land in.

D

The right place in a timely fashion- and we are not there yet.

D

We've made some improvements, but there remains quite a job of work to be.

D

Done and that's really begun and has been pushed forward.

D

In terms of one of the first points of contact for us,, which is through our.

D

Contact centre in Newcastle, the NCSC, I think it's interesting to note that we've.

D

Been undertaking some one-to-one training work with the people who are.

D

The first point of contact, the call handlers and the interesting thing from.

D

That is the average lengths and duration of our calls is actually going up,.

D

That's indicative of better conversations that are happening,.

D

We should celebrate the fact that actually, we may not be hitting.

D

Every target for a call being closed, I think it is because, when we actually.

D

Look, we're having better conversations with people and explaining things better.

D

And our staff are saying that they feel they are doing a better job, I, think that is.

D

A good thing to be happening and we'll be doing more of that.

D

We are beginning now a review of our CRM system and the reason for.

D

Mentioning that, is CRM, really captures and holds a significant amount of what.

D

We should know about where we are and what we're doing and who we are.

D

Talking to and allows us to have those proper conversations with people who.

D

May want to contact us with concerns, and it is not as good as it ought to be,.

D

And we are doing great deal of work to actually understand what a fit for.

D

Purpose CRM tool is for an organisation like CQC, and really working from the.

D

Basis of what do we need and how far away are we from that, so that work has.

D

Begun and is important in this context.

D

We've touched on in a slightly different way, the term experts by experience and.

D

There is a note in here about an increase in the number of concerns being raised.

D

About experts by experience, I think it's important to note that sometimes we.

D

Use that term and it's used to cover many groups of people who work with.

D

Us on a flexible bases,, we have expert by experience who may be patients and.

D

Carers,, we also have experts who may have a clinical professional background.

D

That we're seeking to draw upon, and we need to, as Paul, would say, segment.

D

And understand who we're talking about in this context, and Paul and I are doing.

D

A good deal of work on that in terms of understanding who works with us,.

D

On what basis,, how we're training them,? How we actually manage.

D

The quality of the experience that they're making when they're deployed into.

D

Context and again that is very important as we seek to use more of such experts,.

D

We will need to be very mindful about the recruitment,, the deployment,.

D

The management and the quality assurance of that input.

D

So, that's a piece of work that Paul and I have beginning,. We shouldn't.

D

Underestimate what a complex undertaking it is.

D

But! That's a sense of the work in progress, Chair,. If there's any questions.

D

Please I'm happy to take them.

A

≫≫ Any questions for Eileen? Kay.

F

≫≫ Just a quick comment to say that having a regular report like this to the.

F

Board is really helpful.

F

Complaints are often described as gold dust, and that's how we should see.

F

Them, we're going to be looking at how providers manage complaints so I think.

F

It's good that we are developing our approach and we should lead by.

F

Example,, so it's very welcome.

D

≫≫ Thank you.

J

≫≫ I was really interested in this new complaints, around special advisors and.

J

Experts by experience and people who, strictly speaking, of course, as you say in.

J

The report we don't line manage, but who are acting on our behalf,.

J

I just wondered whether you can tell us whether these complaints related to the.

J

New style inspections or whether they were part of a historic legacy?.

D

≫≫ I think they actually come from both.

D

And, that's that's! Why we're mindful that we have, we're working with an.

D

Imperfect approach and we need to remember that anybody who is on an.

D

Inspection is doing things in our name and therefore the responsibility to make.

D

Sure that there is a high quality and satisfaction with the approach being.

D

Taken is important to us, and that's very clearly what we're setting out as being.

D

The problem that we have to solve.

J

≫≫ I just observed, that, given the scale of the new inspection teams and the fact.

J

That so many of the people on them,, particularly in relation to hospital, but so.

J

Many of the people on them are not strictly employees,. Actually, this is a.

J

Potentially significant risk going forward and something we need to think about.

J

How we manage the arrangements with those individuals,? That's what you're.

J

Doing, just to clock it and say: actually this is a significant risk. Potentially.

D

≫≫ I think we all agree that the risk is understood and we are trying very hard.

D

Now to embark upon bringing about a system where that risk is well managed.

F

≫≫ Just wanted to reflect on the point that you made on page 2 of the report.

F

Eileen, about people feeling that the complaint that they've made about.

F

The service is not reflected in the inspection reports.

F

And there's two things there: I think, one is how we feedback to complainants and.

F

How we feedback more generally, to address this.

F

Because I think that in the main, there is a path that goes, there is a concern,.

F

It's fed through to the inspector,. It does shape the inspection that we undertake,.

F

And one of the gaps we have is not necessarily going back to the.

F

Complainant and saying actually, here's the report and being proactive about.

F

That, and for example, it was via Twitter, but I ended up having a conversation.

F

With somebody who had raised concerns about the service,.

F

Was still worried about it and that came through, and eventually I was able to.

F

Point him to the report that had been published, and he was fine,.

F

Because, actually, we had addressed the concerns, but we'd obviously not told him!.

F

So I think that there is something --, and this was a challenge that the Health.

F

Select Committee put to us about how we inform people of the outcome of our.

F

Reports,- and it is something that we're looking to address in our wave 1 testing,.

F

To see whether we can write the summary in such a way that it can be.

F

Lifted, cut and pasted so that that can provide the basis of a letter to people.

F

Who are using the service,, so we can more proactively handle that.

F

Responsiveness. So there is wider work going on that. Hopefully we can build on.

D

≫≫ I think that's really helpful extra colour.

D

The core principle is. We are trying to ensure that we have a well structured,.

D

Well, understood approach to concerns, complaints and comments that come in.

D

To us, so people do feel a sense of engagement and that we are proactive about it.

A

≫≫ Good,. Thank you very much. Eileen, thank you.

A

C

≫≫ We move onto the business plan for 14-15 and 15-16 a draft plan, the board.

C

Is asked to comment on the draft,: it's a two-year business plan.

C

If I start by saying it's deliberately not attempting to set any particular new.

C

Direction,, it's very much designed to be consistent with and provide additional.

C

Detail on the three-year strategy, and it will sit alongside a two-year road map.

C

Which will focus more on the, how we're doing things and just pulling together the.

C

Story, if you like,, for why the set of things that we're doing will add up to the.

C

Changes that we want to see in the health and care system as regards.

C

Regulation,, and would want that to be a particularly public facing document.

C

In the interests of time, if I can draw people's attention to two bits of the plan.

C

On page 6 of the plan, there is the organising framework that we use when.

C

We're thinking about impact and outcomes of quality and effectiveness,.

C

So that's ensuring that we always have the right measures in place, and it goes.

C

On to page 7, to look at the internal capabilities that we have in CQC as.

C

Well, and then the more detailed success measures are on pages 27 to.

C

30- and these are things the board has commented on in the past,, but just to.

C

Provide that link through not just into the actions and milestones and process,.

C

But how we think, as an organisation, we should be held to account.

A

≫≫ Paul,, it's worth saying, isn't it, I, think for our away day we're going to try and.

A

Write the narrative that goes before this,. This is almost an appendix to the story.

A

Isn't it, so I think we'll have a time to discuss it in more general terms on that day.

C

≫≫ That's right,, so it will be at least an hour for the conversation on the road.

C

Map, as well as the forward strategy and state of care report.

A

≫≫ If people have over the next three or four weeks,. If they have comments.

A

On this do feed it in to Paul, any general comments. Today, people would like to make?.

F

≫≫ Just thinking of our earlier conversation about involving and.

F

Engaging people who use services,- it's not very clearly reflected in this business.

F

Plan,, so we can talk about it more when we meet,, but I would certainly like that.

F

To be, have a higher profile and be reflected, maybe throughout,.

F

It's just to flag that up as an issue.

C

≫≫ Let me take that one away,. We have clustered it in priority 1 of the feedback,.

C

People who use services,, but if it's not coming through enough, we can do.

C

More, thanks Kay.

A

≫≫ Anyone got any sort of fundamental issues: they'd like to raise?.

A

I think it's a good document. Paul actually.

A

J

≫≫ No, it's just that I know there is a link in this document or there will be to the.

J

Strategy, but actually when you go to the strategy, what you see are the six.

J

Strategic priorities that we've got,, then what you get in the business plan are.

J

Three business plan- priorities, I'm just began to have the feeling. Maybe we.

J

Were drowning in levels and differences and I just think there's something really,.

J

Really important about simplicity, here, using the same framework and following.

J

It through, so when I read the detail, it all made sense, it kind of -- I, know.

J

Where it's coming, from, we've had conversations about it,. It involves the.

J

Things we've said we're going to do,, but I just found it difficult to join it all up in a.

J

Way which made perfect sense and I think we may have over complicated.

A

≫≫ I think what we're lacking is one document which is coherent right. The.

A

Way, through,, which is the narrative and the business plan really,.

A

I think that's what we're working on! Isn't it Paul,? That's a good point, I agree with you.

G

≫≫ Just one other point following the point I made earlier about the.

G

Bureaucracy issue, I, remember when you were talking to me about coming on.

G

To this board, it depends who this is for.

G

If, you don't know much about CQC, it's very hard to understand what it used to.

G

Be like and how it's going to be different, I just remember somebody saying to me.

G

Very early on, well, we've reduced the number,. We used to have X number of.

G

Indicators now we have far fewer, I just think it would be nice to reflect.

G

Somewhere in here that there has been a more intelligent approach to.

G

Monitoring, I know it says that,, but it's not clear what it means for a provider.

G

And that part of that drive was to try and remove unnecessary ridiculous.

G

Compliance requests to providers,, because that would be quite reassuring,.

G

If you read this is,, all you can see is more and more pieces of paper landing.

G

On your desk and actually I, don't think that's our intention.

G

You know what I mean? I thought it would be nice to get in there,. One of the measures of success is we.

G

Don't create compliance teams of 50 people in every organisation,.

G

Because that's not our objective is it?.

C

≫≫ Definitely, not our objective, to create those teams in all seriousness...

C

...But, the fundamental challenge,: what isn't going away are the fundamental standards, so we have to --. The DH draft doesn't really reduce the number of.

C

Things that we need to inspect against, so...

A

≫≫ I think the point that -- I think the point Camilla is making is the point that.

A

Ed Richard made at Ofcom,, which is at some point, we'll be judged whether.

A

We're delivering good value, and that means removing costs from the people.

A

That we are regulating and keeping our own cost structure to the absolute.

A

Minimum as well, is that part of what you are saying?.

A

No? Clearly not.

G

≫≫ I'm sorry I feel I, never explain myself properly on this issue.

G

I just think a lot of providers see us as a very top heavy, unwieldy, bureaucratic.

G

Organisation and some of that report, and obviously that was the old model,.

G

Said things like it's untidy, we don't know what we're expected to bring, I've been.

G

On inspection and you arrive and they wouldn't have the papers --, the new.

G

Model is supposed to be much better,. That's all I'm, saying so. Let's say that.

K

≫≫ It seems to me one of the outcomes could be that providers say they have to.

K

Spend less time working with CQC.

G

≫≫ This is what you've never been prepared to say, this table, we've never.

G

Been prepared to say that,, it would be an interesting tack,. Can we say that?.

A

≫≫ Press the button, Camilla.

G

≫≫ Sorry,, it's great if we can say that,, but if we were going to measure that.

A

≫≫ But, we can measure that.

C

≫≫ We absolutely can and we'll reflect that, but I am also very conscious that.

C

We're not bringing two people into a hospital we're bringing in 30 people and.

C

We're asking for a great deal more data, because we want to make comprehensive assessment, because we didn't in the past, and what we need.

C

To reflect is the truth of what we're doing and challenge ourselves to make it as.

C

Least bureaucratic as it can be, as well comprehensive.

G

≫≫ I'm mainly talking about social care, where I think people feel rightly a bit fed up.

B

≫≫ I think it's a great challenge and I'm absolutely clear what you've said and.

B

Why, so on Friday I spent four and a half hours sat with a registration, assessor.

B

And she showed me what happened from the call coming into Newcastle to.

B

What she had got to do to issue a certificate.

B

And on one thing, to change the registered manager of a dental practice,.

B

So to deregister the current and register the new, I counted 50 clicks of a mouse!.

B

So, it's absolutely spot on., And I think there is something in here that says about making our systems more efficient.

B

Now I think the audience for this is our inspectors and our key stakeholders,.

B

The narrative will be the public facing document,, one of the things I want to do.

B

After this meeting is send it to some of our key stakeholders and say: are you.

B

Clear about it, I think it will be read by people with inside knowledge,.

B

I, wouldn't give it to me dad!.

B

But I would give the narrative to me dad,, because I'd want him to understand why.

B

We're doing it,, not the detail of the measures,, so I think there is a trick.

B

Maybe you can help us on this.

B

Paul pulled out the narrative at the front, Paul's team worked on this, I've had.

B

No contribution to this, but just getting that graphic right about. Why are we.

B

Here,, what outcomes are we looking for,? How do we measure it and picking up on.

B

Your point, good challenge as well Anna,, get the simplicity of this is what we need.

B

To do, I don't want to put everything to later this afternoon,, but there is a paper.

B

On evaluation, which is critical to this,, the good thing is we're having these debates.

B

And they are transparent now and in public and we're forcing them through.

B

And this will help us push into that much further,, because ultimately, I tried to set.

B

This out in an internal note,, one of the issues from the challenge to Ofsted,.

B

Is how do we know? We've made a difference? And, we need to be able to demonstrate it and we haven't got any time to start demonstrating that,.

B

The clock is ticking now., It's hugely important issue. We need to get right,, that's what we're trying to do in.

B

This without counseling perfection to be honest.

A

≫≫ Michael, have you got any comments on the business plan?.

L

≫≫ I've only really got one,. Paul's got a paper later today on cost benefit.

L

Analysis, which has actually got a slightly different framework from that on page 6,.

L

Of the business plan and I think it is quite important that especially the way.

L

We try and measure impact,, which is the point I've just made,, is consistent across.

L

These various documents that we are publishing, and, of course, that we hold.

L

Ourselves to these measures, I actually thought the one in the framework in the.

L

Cost benefit analysis was probably,, even though it was more complicated,.

L

I thought was a more rigorous framework than the one on page 6 and I.

L

Wondered if that should become the framework for the business plan as.

L

Opposed to the page, 6 version.

C

≫≫ So, what we've got in the business plan is an attempt to scale down the.

C

Version in the fuller evaluation piece,, quite frankly, if it works better to have the.

C

Full detail in with that, one extra part around the costing model, I just hope. The.

C

Board steering will use the right one.

A

≫≫ There are two documents,. The narrative is the one that David's dad --.

A

I, don't know David's dad, but he's the one or your mum Andrea, needs to be.

A

Able to understand... >> The mum's test. >> But, what's behind the narrative, is what I think we need for our own people,.

A

Staff within CQC, but also for the Health Select Committee and providers and the.

A

Like,, but we do need to have one coherent document which all ties.

A

Together, I think., Excellent. Look it's time for coffee,, so have a break for coffee.

A

≫≫ Right, Paul, the new approach to thematic activity.

A

>> So there's been a series of conversations at the board on thematics,.

C

Back in the last part of the last calendar, year.

C

We had the overall discussion and then the next board meeting there will be a.

C

Presentation on the suggested topics for the next six months,, Q1 and Q2 of.

C

14/15, and this paper sits in the middle of those two and is aiming to set out in a.

C

More detail what the principles of the new thematic programme approach.

C

Should be,, so the ask of the board is to agree the direction of travel.

C

The highlights of the report. I'll keep, not trying to go through it, are a suggestion.

C

That we dedicate two and a half to three percent of the operational resource of.

C

The inspecting directorates to providing this authoritative voice through thematic.

C

Work, and that we think that would translate into up to four very significant.

C

Thematic pieces in a given year and up to 12 smaller,, but still significant, pieces.

C

We've had a number of conversations about how the link takes place between.

C

The thematic work that I lead, and the integration work that Steve leads,.

C

And there clearly is overlap and Steve and I work really closely on this and.

C

Steve's lead Matthew Traynor as well,, but it's also teasing out the difference,.

C

The difference being that the thematics are national as a general rule,, whereas.

C

The work that Steve will lead has a local flavour, so it will tend to look at the.

C

Quality of care for an individual across a whole series of services in a locality,.

C

So, quite clearly those two things can come together,, but there is that difference.

C

The other part is that although, by definition, Steve's integration work is.

C

About the integration of care, through the eyes of a patient or person using.

C

Services,, not all the thematic work will necessarily be about the integrated care.

C

Agenda,, we may take a particular theme of say safety,, so those important.

C

Differences, but very linked programmes.

C

If I could draw people's attention just to two particular parts of the paper.

C

If we look to page 5, midway down, that sets out what the purposes is of the new.

C

Approach to the thematic programme- and this follows the discussions of the.

C

Board,, so we think there are three things that should really determine why we're.

C

Doing a thematic,! So if it's just about telling people what's already known but.

C

Codifying it,, we don't think that's good enough, if it's something that lots of.

C

Other people could do,, we don't have a particularly authoritative position on it,.

C

Then again we shouldn't be doing it,, because there is so much that we should be authoritative, on, and if it just provides a running commentary rather.

C

Than encouraging improvement, as per our purpose,, then again, that's not a.

C

Good enough reason to do it. So, that's the purpose part,. If we go to page 8, and the very top, where we look.

C

At the proposed priorities for the 14/15 topics,, we'll bring those topic short list in.

C

The next board meeting,, but we think the four main areas to focus on for.

C

14/15 are quality from the perspective of people who use services, particular.

C

Focus on safety, we'll look at critical risks generally, but we think safety is a.

C

Particular theme.

C

We want to look at the care journeys across services and the integration of.

C

Care- and we want to look particularly at the inequalities of work,, particularly with.

C

People in vulnerable circumstances,, so to give the counter example, it is less.

C

Likely that we'll spend our time thematically looking at the effectiveness.

C

Of cardiovascular services in hospitals,, just as an example,, it's important, it's not.

C

To be disregarded,, but it's something that Mike can pick up directly through his work.

C

I think I'll leave it there,, but that's the main elements.

A

≫≫ Thanks very much Paul,, it's very good to have a theoretical basis around.

A

How we assess what to do, I think it's important to do. That.

A

Do people -- are people convinced by Paul's paper?.

A

H

≫≫ I must say, I think it's very good, I, like the principles,. The four bullet points.

H

You just highlighted, care across the different parts of the system is critical,.

H

I was --, I joined an inspection of a care home recently and one of the main.

H

Issues was the medicines management, and yet that wasn't what we were there.

H

To look at,, it was about the GPs going into them.

H

So I think that's absolutely crucial, I think that's a key thing.

H

I suppose there's another catch-all, other gaps in the system, which I think.

H

Anything that doesn't fit our other methods probably ought to be addressed. This way.

H

What I'm not sure about is the role of the board, so Paul. Maybe you could.

H

Clarify that,, it seems to me one way in which this system would work. Well, if.

H

There is quite a short lead in time, I'm, not quite clear what lead in time you.

H

Have in mind,, but it could be short,. Sometimes the process behind clarifying.

H

The exact Terms of Reference of a review can get in the way of doing the.

H

Review in a timely way- and there are other NHS organisations that have fallen.

H

Foul of that, over the last few years, I would say, and you can spend so long.

H

Getting the exact purpose right that, in the end, you've missed your timing,.

H

So I would suggest an early identification of topics and maybe the board has a.

H

Role to play, there. It is written as if our role is to take the provisional list of topics from the.

H

Thematic activity strategy board and approve it,, whereas actually I, think we.

H

Should have a stronger say in what the topics ought to be,? We were already.

H

Doing this online in response to emails that came around,. So can you assure.

H

Me that he will we have an input into the topics. Themselves?.

H

≫≫ Yes, absolutely the email has already gone around asking for views of the.

C

Board on a much longer list,, it certainly shouldn't be a tick box. Yes, that's fine,.

C

If there is things to be proposed or debated, other big areas that need to be.

C

Included that we haven't got,, we should do that.

C

I'd ask if we could get those ahead of the main board meeting just so we can.

C

Do the necessary work on them in advance.

F

≫≫ Just to make a comment, and it's a really helpful paper. Paul thank you,.

F

One of the benefits of this,, although I can understand that we wouldn't.

F

Necessarily set it out as a purpose,, but one of the benefits of this is how it helps.

F

Us to improve our inspections on a day-to-day basis,, so the thematic.

F

Inspection that was done around dignity and nutrition,, and the one done around.

F

Home care, there were some aspects of the methodology that came out of that.

F

That very helpfully feed back in, I didn't quite get that from the paper and as I.

F

Say, I can understand that we wouldn't be saying that as a primary purpose,.

F

But it would be really useful to keep that in mind that some of the learning is not.

F

Just for the sector, but for ourselves as well.

C

≫≫ That's absolutely spot on, and we know there are areas of our ratings.

C

Across the different sectors, where we are more or less comfortable, I think we.

C

Should absolutely look to test areas where we are less comfortable and see.

C

What the standards of good look like through thematics.

F

≫≫ I was going to make that point as well,, but I just wondered if we could.

F

Actually be very specific about that, particularly now, because we are.

F

Developing fast and I think it would be valid to make it part of the purpose,.

F

It can be reviewed, but given that there is so much we are developing,.

F

I'm interested in views, but I think there could be some merit in making that a.

F

Core part of the thematic reviews,, certainly in the short-term, as we develop.

F

--, just a thought.

J

≫≫ Just, a general plea, I can see lots of values to thematic work and the one.

J

Described is another one which perhaps isn't properly emphasised, I've got some.

J

Rather bitter experience of thematic work in an otherwise sectoral regulator.

J

Though,, which is that it is always -- not to say it will be here,, but it is naturally a.

J

Poor relation,, when you are set up on a sectoral basis and one of the reasons.

J

Why it's really important that it shouldn't be a poor relation? Is that it's the place.

J

That you have the opportunity to look at the way things are in the round for.

J

People, a well rehearsed argument around this table. That's partly about.

J

Integration of services at a local level and I appreciate the differentiation you.

J

Made there Paul,, but it's also about looking at the issues in the wider sense.

J

Across the whole population and whole service provision,, that for me means.

J

There is a really strong case for us, doing, us having a very good.

J

Programme of thematic work, which is very heavily dominated by looking at.

J

Groups of people and the way that the area we regulate delivers for them in the.

J

Round, and I'm very glad to see on page 8 of that list of things,. Although people.

J

Are rarely mentioned in the early parts of this paper, by the time you get here.

J

There's three priorities,, which are very much --, proposed priorities which are.

J

Very much about that and that feels right to me, but I guess the other caution. I.

J

Have around this is that --, so there is an issue about challenge for time. In this.

J

Programme and the extent to which the people user issues are given enough.

J

Space and there's also a second challenge in this paper, which is about.

J

Resource, because it depends not on dedicated resource but on resource.

J

Being provided from what will inevitably be pressured directorates doing the day.

J

Job the CQC does of everyday inspection of all of these institutions,.

J

And I can just feel a kind of pressure on priority and a pressure on resources and.

J

All I can do is say, please, let's be very careful with what is a very precious.

J

Resource and the way that we have always said we'll compensate for the.

J

Sectoral approach, which we have necessarily and appropriately adopted,,.

J

But we need to protect it for these things and make sure that the time genuinely.

J

Is available from the people who are in the three inspectorates.

E

≫≫ I just wanted to again support the general direction of this,, but particularly.

E

To welcome and encourage the clarity with which the difference the potential.

E

Studies are going to make, should be explained when they are put to the.

E

Board, so I entirely support what Louis said about making sure there is a wide.

E

Spread of choices,, but also could those choices then set out how the outcome of.

E

The report will benefit patients, users,, the wider public, rather than simply being.

E

An interesting topic that we around the table might feel we would like to pursue.

G

≫≫ Thank you very much for providing appendix 1,. Can you just put into.

G

Numbers what 3 percent of operational resource equates to?.

G

Because I, don't know how much that is.

C

≫≫ About 45%., >> Which, is how much money?.

G

≫≫ Because: this is the opportunity cost of this, it's very important,. This is not free.

G

Resource,, this is money that we could be spending on other things,, so I just think.

G

It's useful to have that in mind,, because a percentage doesn't necessarily give you that level.

K

≫≫ And each review is five staff years.

K

Five years of staff time,, which actually is another way of putting it,, that's a lot.

K

I think what's been useful about this discussion is what's been asked of you.

K

Paul is to come up with a set of internal outcomes,.

K

I.E. how will this improve our work, and your example about medicines.

K

Management seems to be,. Therefore, we've got to do things with that,.

K

Because otherwise, we're just making recommendations for other people to do.

K

Stuff,, which the easiest thing in the world to do,, then they don't do. Is it as.

K

We've found with everything else.

K

So. What comes out of these things has to be a part, because actually care.

K

Journeys across services and integrated care,, you don't need five man years to.

K

Explain, that, they're bad!

K

We know, and they may be very, very bad or just very bad..

K

But, actually, we don't need five staff years to find that out.

J

≫≫ We probably do need five years to work out how to build it into the inspection regimes.

A

≫≫ It is the critical --. Is it worth doing,? That is the point? Isn't it?.

A

Just producing an interesting paper that no one bothers with is pointless.

A

≫≫ Absolutely. >> That's the rider,. If we can agree 2 and a half percent or whatever it is,, it is.

A

Subject to finding something worth doing.

H

M

≫≫ I strongly support this and the use of the resources, and I think it can drive.

M

How our state of care report really makes an impact on care as well,.

M

It will affect everything we're doing to make what we're doing at CQC, more meaningful.

M

Just, to take up an example that Louis raised about prescribing in.

M

Care homes,, we know the evidence base on prescribing in care homes is it's Tony.

M

Avery's work from Nottingham University the errors break down roughly.

M

20 percent,, the doctor prescribing,, the pharmacists interpretation of the.

M

Prescription, the care home whether they give the right drug at the right time.

M

Or whether the patient is capable of getting the drug, and it's an ideal.

M

Example of how Andrea and I will work together,, and this board has supported.

M

Me in doing a review of our medicine management team, which is on-going.

M

Now,, because we have a team of pharmacists which look across all three.

M

Sectors which I house,, which will need to expand.

M

Now, that's the sort of example of how a thematic might change, how we inspect.

M

And as we're building our inspection model for primary care from the bottom.

M

Up, as we go into a CCG area, we'll want to get more feedback from care homes.

M

And from users of the service,, and we can look across sector all the time.

M

Where Paul's leadership is really important is that these can be,. These will.

M

Be national and have national impact,, but we might test out the work.

M

We're doing and we might change what we're doing as the base of the thematics.

M

And I see the board as being a really important part of this to debate. The.

M

Priorities and look at how we can really have a massive impact on care. Generally.

L

≫≫ This is a point. I had thought of making. When you asked me out of the.

L

Blue, what I thought about the three chief inspector's reports, but I think.

L

Mike,, Steve and Andrea, all in different ways have I think suggested. An.

L

Opportunity, which is that if, over the next year, one of Steve's clinical.

L

Commissioning group areas is the same as the, one of the Trusts. That Mike is.

L

Going to be inspecting in what might be wave, 2 or wave 3 and is also a locality.

L

In which Andrea is going to look at various types of care, home and.

L

Domiciliary care, I think the ability to provide this --. This is what the NHS.

L

Looks like, or the NHS plus private care homes looks like when we take a very.

L

Specific area,, and also it gets to, to some extent, Paul's point about how this all works. Together.

L

I think it would be a very important subject for us to have, and it may.

L

Actually even, in terms of resources,, maybe it's really the, makes up a third of.

L

The thematic work,, because it is so important to give this overview of the.

L

System, and I think only the CQC can do that,, because it has these three very.

L

Specific inspectorates,, quite a lot of the other work that we --. That I think some.

L

Colleagues suggestions,, although all of it was interesting,, other people are doing.

L

Bits of it and may be in a position to do other pieces of work better or at least.

L

Equally well,, but this is something that only CQC can do, and we should have.

L

The skills to do it really superbly, such that there is very deep insight into here.

L

Is the system as a whole and here's where we see problems, issues, need.

L

For reconnections, a different way of doing things, a whole range of cross.

L

Inspectorate issues.

L

If we could nail it I'd, be keen on that, as it happens, to be a centre-piece of the.

L

Next state of care report, because I think I'd add to Paul's criteria,. They should be.

L

Only things that only the CQC can do, there is something about our knowledge.

L

That means that we've got special insight into whatever the thematic reviews turn.

L

Out to be,, but I am keen on this cross system thematic review, because that.

L

Just seems to me, having listened to the chief inspector's report, something which.

L

Is uniquely -- we do have just a unique capability.

M

≫≫ I'm so pleased you said that,, that's the rationale behind why I'm here,.

M

To try and drive that particular agenda, I think we have a chance in a generation.

M

To sort something out using CQC as the key body for driving change,, because.

M

This will affect commissioning and we'll clearly be able to look at how we.

M

Commission, not just an issue of local authorities,, as David rightly said earlier,.

M

On,, this is about commissioning across health in its various forms,, but to just.

M

Extend that, some of the discussions we've had within the last 7 days, with.

M

The chief inspector or HMI Constabulary,, we should be speaking out much more.

M

About some of the abuses that are happening in health, generally,.

M

For example, female genital mutilation,, domestic abuse,: we can work closely.

M

With our colleagues in other inspectorates to focus on important.

M

Issues, and I see that as part of the integrated work,, this is about health in.

M

The broadest sense of the human beings who live in our country.

A

≫≫ Michael, thank you for that, Paul. Are you happy with that?.

A

Good thank you.

A

John, audit and corporate governance committee.

E

≫≫ I think I can be succinct and say I'm happy to answer any questions that.

E

Arise in it or from it.

A

≫≫ I have one question for you: if I can, the gateway review that was done,.

A

Which you obviously looked at in some detail, I, didn't read it to start with, as.

A

Close as I should and formed the view that, basically, we were doing fine, with a.

A

Few caveats, and that was obviously an incorrect reading,, because the criticism.

A

They had or risks they were flagging. You felt were quite serious.

E

≫≫ Yes,: that's why we've said that, I've talked to Hilary about this, that the.

E

Statements which are being prepared as a result of the gateway review, which are.

E

Basically, the overall statement of what it's trying to achieve and how it's trying.

E

To achieve it, does need to come to the next meeting of the audit committee,.

E

So that we can then examine that and report back to the board,, that's what I.

E

Hope we should be able to do.

A

≫≫ If, you can do that for the next meeting and give the board assurance.

A

Or otherwise, as to how the transformation programme is going, that.

A

Would be helpful, thank you.

F

≫≫ The gateway review that was done in November was an assessment of.

J

Deliverability of the programme at that state in time, they made really useful.

F

Recommendations about our overall ability to define our end state and.

F

Our progress towards it,, but their confidence in our deliverability was a positive one.

F

≫≫ Could we be sent a copy of the report, I, don't think we have had it yet?.

A

≫≫ Has it been sent around or not?.

F

≫≫ It has, but we can resend it.

A

≫≫ There's so much,, if you can resend it round,, does everyone want to see it?.

A

Yes please, send it around to everybody.

A

John,, if you could --, that's obviously part of the feedback, maybe for the next meeting.

F

≫≫ As Hilary quite rightly says that was a report that was in November,.

F

And actually, we've done a ton of stuff since November in terms of moving the.

F

Programme on both from development of new approach, movement into the.

F

New directorates...

A

≫≫ Just a reference point, we've moved on from that,. We all know: we've moved on from that.

F

≫≫ Just reading it in that context would probably be helpful,. That's all.

E

≫≫ I think the committee,. The audit committee would be very happy to have.

E

The explanation of how some of the risks which were identified in the gateway.

E

Review,, which, as you say, was a few months ago, now, have been mitigated to.

E

A greater extent than have been identified in, when the gateway took place.

J

≫≫ We'll do that for the March board and I would also like to provide an end.

F

Of first period report back to the full board on what we've done,, what.

F

We're doing next and we have a next gateway review scheduled for June,.

F

July time next year, as well.

E

≫≫ As I say in my report,. The committee fundamentally supports the purpose of.

E

The transformation programme, and recognises that it is central to achieving.

E

The changes which we need to secure for the commission,, but it's a big ask,.

E

A big challenge, and it does need to be kept on programme and both in time.

E

Frame and the breadth of what's being achieved,, it's a really difficult, challenge.

B

≫≫ I think we should see this as being a really helpful piece of work to just get.

B

John on a committee to just do a check,, because whilst we did get the gateway.

B

Review I think I said to the board. It was positive because that's what the.

B

Principle reviewer said to me when she debriefed it back to me, that said, John's.

B

Point that he just made about this is a massive programme and the degree of.

B

Risk in it, we've just changed: 1500 people's jobs, Michael's often said we're.

B

Going to take on 500,, which is as big as taking over another organisation and.

B

We're doing that simultaneously, while changing every method we've got,.

B

So, actually being open about how we're mitigating and dealing with it and having.

B

A really open conversation in detail at the audit committee and then reporting.

B

That to the board, I think will do nothing but good,, so we should actually go at it.

B

In that spirit, I think.

A

≫≫ Thank you. Michael, the governance and value committee.

L

≫≫ John very kindly chaired the committee in my absence,, but I think the.

L

Committee had a very good meeting and I think there's a pretty clear programme.

L

Of work ahead for the committee, and I think Clare's minutes, I, think I discussed.

L

This with John, accurately describe the last meeting, so happy to have any.

L

Questions to John and myself.

A

≫≫ One Mike,, if I could,, the patient, complaints and raising concerns are a.

A

Big issue and we're generating quite a lot of debate, particularly around.

A

Whistleblowing and raising concerns at the moment, and we do need to bring our.

A

Stance to a conclusion at some point, how far, I know that we've just.

A

Instructed Kim to do some work for us haven't we,, but when do you think we'll.

A

Be able to bring it to a conclusion?.

L

≫≫ Well we've also commissioned these two external reviews,, which the.

L

Cqc was I, think committed to undertaking,, so I think it's going to be.

L

Another two to three months before these various reviews are finalised,.

L

But I was unfortunately, I had to cancel it, going to see Eileen. This morning,.

L

Because, as you saw in the paper on complaints,, this is a very integrated set.

L

Of issues and set of challenges,- and we do need, I- think everybody agrees,.

L

To come up with a CQC way, of...

L

...Understanding and using complaints and whistleblowing.

L

I think the one conclusion of the regulatory governance committee is that.

L

There is a very small distinction between the two.

L

Having said that I went to, as David did,, the whistleblowing event that Kim Holt.

L

And James, Titcombe, held, and I think there is undoubtedly pressure and a.

L

Feeling that the CQC may be able to be that point in the system which really.

L

Does provide support to whistleblowers such as that in a way whistleblowing.

L

Becomes such a normal state of affairs that it does actually transform itself into.

L

A just culture, which David's described,, so it is a challenge for us,, but the end.

L

Point of the challenge would be a very good place to be, because as I say,.

L

It should move us towards encouraging cultures in the providers that the CQC.

L

Inspects,, which mean that is, we might actually be able to abolish the term.

L

Whistleblowing, or have a term which more accurately describes what we.

L

Really do want to hear from people.

A

≫≫ I'm just conscious the Health Select Committee are doing a study on.

A

Whistleblowing and raising concerns at the moment and they've asked us to submit evidence by March, 17th or some time in March,. I. Think we'll need to.

A

Submit something at that point, before then,, so Michael I, wonder if we can ask,.

A

If we draw up a draft for you to look at, I, don't think your committee is meeting.

A

Before then,, maybe you could circulate it around to people and get their sign off on it?.

A

F

≫≫ And just to say it is something that we are thinking about across the sectors.

F

In terms of how that's being taken into consideration in the lines of inquiries,.

F

That inspectors will have,. So how are organisations listening and responding.

F

To the concerns of staff and anybody else, about the service,, including.

F

Whistleblowers,, but actually trying to get in the language that we should be.

F

Listening before people become whistleblowers, because actually it's.

F

Responding in a much more proactive way that needs to happen,, so I think that.

F

There's probably something that can feed in on that and the work that Paul's team.

F

Is doing is consistent across all three of us would be important, too.

A

≫≫ Thanks. Do: you want to do that?.

B

≫≫ So David, just to set the work that Michael's overseeing through the.

B

Committee in a context,, the permanent secretary and the Department of Health.

B

Was asked by the chair of the Public Accounts Committee a question about.

B

Whistleblowing, and in answering that the permanent secretary gave an update.

B

And then we have been asked to make a statement to the permanent.

B

Secretary, which will then be sent today, I think, to the chair of the Public Accounts.

B

Committee, and in preparing that answer,, this issue about precision of.

B

Definitions came out,. What we did have following Winterbourne was a.

B

Whistleblowing hotline, which has been redefined as safety escalation, hotline,.

B

We were counting --. This is where some confusion had come. Through,.

B

Calls to that helpline, and I think when we were in Newcastle a number of you.

B

Sat by people taking these calls and listening to them.

B

And we've quoted figures 7,000 and a few or 8,000 and a few for last year and.

B

The year, before, and I think that's been interpreted in some quarters by some.

B

People as being there's 7,000 or 8,000 whistleblowers,, actually, what we've had.

B

Is 7 and 8,000 people raising concerns, of which some have been whistleblowers.

B

The system we've got is that colleagues in the safety escalation team,.

B

Up at NCSC, track those cases through and we're clear about handing them.

B

Over to an inspector where they end up, and what's been clear from preparing the answer.

B

There are a number of cases where we've not recorded on our customer.

B

Record what the outcome of those cases have been.

B

I'm told they have been followed up,, but, of course, if there's not a record,.

B

There's no evidence that they've been followed, up.

B

They've all been triaged, passed through,. The issue isn't that they've been.

B

Left untouched or unacted upon,, but it raises the issue of where have they.

B

Gone and what action has come through on them,, there is a smaller number of.

B

These, which are whistleblowers,, 500 and 600, I, think I can set this out in a.

B

Letter if it would help, as I say, this is something that's just happened over the past few days.

B

So as we develop our methodology,, we need to make sure it's not just our policy.

B

And strategy- that's right,, but the detailed operation of this and I think we need to.

B

Be much clearer in breaking down the numbers into what the nature of the.

B

Concerns are, and what are the action has been to follow them. Through,.

B

So those which are genuinely whistleblowers in the terms of these are.

B

Employees who have made a declaration to a designated body- and they are then.

B

Protected by what is effectively employment legislation that their.

B

Employment will be protected, as distinct from people raising concerns whether.

B

They're employees or staff about the quality or safety of care where action is required.

B

I think we need to do more to use the phrase from earlier today to segment.

B

Those numbers coming through and then we can be clear about where they.

B

Go to within CQC and what action we take in relation to each one,.

B

So we need to log them and track them. Through.

B

I think one of the things that we are going to do, because of the uncertainties.

B

That we now have in relation to a number of these referrals is to do some.

B

Audit work, to just check on a sample of these, to make sure that we are.

B

Confident we know what's happened and we'll put that arrangement in place and.

B

Report back to the board.

B

So, the purpose in raising it is just to make this absolutely transparent. That.

B

This is something that's come to light as a consequence of answering a question,.

B

We'll include this in the evidence that we send in to the Health Select Committee.

B

And once we've drafted that evidence to go to the Select Committee we'll set that.

B

In a separate note to go to Margaret Hodge.

B

We know the NAO are going to do a review of CQC sometime during the.

B

Year and I think we should anticipate, whilst they don't all go to the Public.

B

Accounts Committee,, we will end up going back to the Public Accounts.

B

Committee before they finish their work during the next parliamentary term,.

B

So we'll continue to make this transparent, as we begin to work on not.

B

Just the strategy,, but the systems and processes that we've got in place to deliver them.

A

≫≫ I feel uneasy in this area still to be honest with you, I think in between.

A

Inspections, the absolute key source of information that we're going to get will.

A

Be patient complaints and staff raising concerns, and we've got to be --. We've.

A

Got to have a system in place that deals them really effectively and we can.

A

Demonstrate we're dealing with them effectively,, as well as a strategy for.

A

Listening to people better and enabling people to raise issues in the first place,.

A

I, just don't feel that we're quite there yet.

A

And I'd rather glibly said we have a hotline in Newcastle, but without actually.

A

Really digging down to see how effective that is; I think we do need the.

A

Real assurance of whether that is working, well.

A

Eileen I know this comes with you,, whether you could in maybe the next.

A

Meeting or soon give us some assurance of how it is working,, please?.

D

≫≫ I also recognise what you're talking about,. We are embarking,, as I talked.

D

About earlier, into the complaints about bringing together a much more.

D

Coordinated way of working,, Paul and I share an interest in a footprint in this.

D

Area,, so we are trying to make the coordination work,. We want to go from a.

D

Point of actually wanting to encourage people to see CQC as a place to come.

D

To, for us, then, to being able to capture and work through and evidence what.

D

We've done and then to learn from it,. There is a virtuous cycle to all of this.

D

Work that we really have to make work for us, and we are away from it. David,.

D

But nor are we completely broken and I think we are somewhere between the.

D

Two and it's that journey that we are embarking on and the whole set of.

D

Activities that need to happen to make it work, and certainly can come back and.

D

Talk about, I'll be talking with Michael when we're able to sit down together,.

D

Just about how we do make all of these components work together,, but there is.

D

An issue of philosophy which is about we welcome and encourage and then an.

D

Issue of practicality,, what do we do and how do we track outcomes and ensure.

D

We learn and systems learn from what is coming through the door,. That's bigger.

D

Than me,, it really is an issue for all of us.

B

≫≫ I think Paul wants to come in David,, but I think it's Paul and Malta that need.

B

To lead on the development of this and then we'll hang the delivery and.

B

The implementation off that.

B

I think what my briefing is doing is actually saying there is a disconnect in.

B

Terms of when it leaves NCSC, the stuff that's going on in NCSC would appear to.

B

Be fine, although there is some definitional issues, we need to tidy up.

B

At the minute, what we've got is one place where all concerns come,.

B

They effectively triage them,. They then need to be handed over to an inspector,.

B

So it's at that point I think we need to be absolutely clear what people are doing.

B

With it and how it then informs any reactive inspection, we have,.

B

Whether that's a reactive inspection of the hospital,, because it's a clinical.

B

Concern, or a reactive inspection of a care home and I think what the figures.

B

Are exposing is it's that bit of a system that we actually need to attend, to,.

B

The other issue we've got to attend to is how we define things as safeguarding.

B

As distinct from quality issues that we need to address.

B

So, we just need to be absolutely foot sure that we're clear about what action.

B

We are taking on the referrals, and we aren't handing off to anybody else. The.

B

Responsibility for something and we're taking it, I think it fits to some of the.

B

Earlier conversation to be honest about clarity of role and clarity of action, that.

B

We need to take once we've accepted something we need to act on it,.

B

But I think Paul wants to come. In.

C

≫≫ There's a big link to the paper coming to the next board meeting around unexplained deaths in care and other serious safety incidents,, because.

C

The challenge for us is to say what is the --? What are the events so serious that.

C

We hear about that, they will automatically trigger a piece of.

C

Regulatory action,, whether that's an inspection or otherwise, versus the.

C

Professional judgment we give to our inspectors to say there is a mass of.

C

Evidence and somehow they weigh that collective evidence up to make a.

C

Decision about whether to bring forward an inspection or contact the provider in.

C

Some way, this will vary sector to sector,. It's a really important piece of policy.

C

Work that we do,, so that we can give clarity to our inspectors and clarity to the.

C

Public on their confidence,, they know when we're going to act and, of course,.

C

The back stop position is: how could we not -- if we decide not to go in on the.

C

Basis of a single incident and something awful has happened or happens in the.

C

Future and we're rightly going to be held to account for that,, so I don't think it's.

C

Something we can leave floating,, but it's a proper and significant piece of policy work,, whether it's whistleblow or something from a member of the public.

C

Or whether it's death in detention or other serious safety, incident.

A

≫≫ This is an issue I discussed with Jennifer Dixon, I should have said at the.

A

Beginning, apologies, she's away today, that when the Healthcare Commission.

A

Was working,, they had pretty clear guidelines, how you would,, if you like,.

A

Triage what you do with information, and I think --. There have been two cases.

A

Recently, where whistleblowing complaints from a particular hospital,.

A

Are they serious enough to justify an immediate inspection, or do you wait for.

A

Six months and do the inspection in the normal course of events?.

A

And, of course, if you decide not to do an inspection, then something awful.

A

Happens in that place,, so I think we do need to have a system in place,.

A

Which I think is what your policy is going to address. Paul.

A

≫≫ I'm in violent agreement., >> The board needs assurance that when issues are raised that they are.

A

Dealt with in a certain way, and there are certain thresholds which might or might.

A

Not trigger an inspection or some other,, something else.

J

≫≫ I don't want to complicate,, because I think you're exactly right that we need to.

J

Be on top of this, such that what's coming into the CQC, is properly used.

J

And responded to,, but I just think it's worth --. This is something we've talked.

J

About at the regulatory governance, committee, is that there are in a way two.

J

Questions here, one is about making sure that we do what we are supposed.

J

To be doing right, now,, better and well.

J

And I think what David is describing in terms of making sure that what.

J

Happens in Newcastle kind of finds, gets through to the right people and the.

J

Right actions are taken is absolutely about,. We've got the frontend, we need.

J

To make sure the rest works efficiently and effectively, and we can put our.

J

Hands on our hearts and say: we've sorted, that.

J

There is a kind of different question,, which I think is right to take a slightly.

J

Longer term approach to,, which is that there is a big piece of work in the wake.

J

Of Francis and Cluid Heart and all of those reviews which is signalled in hard.

J

Truths which is about so what should this system look like across all of the.

J

System players? And that should, I would hope, mean that in the future there will be a clearer.

J

Sense of what CQC's particular role in complaints- is,, not just what we do with.

J

What we get in through our front door,, but what our role in that system is,.

J

And what we're saying to -- what we and all the other agencies who have a part in.

J

This should be saying to the public about how they negotiate their way through the.

J

System and what support is available,, that's a bigger thing and I think it's really.

J

Important because it needs to be a system wide response that we do, that.

J

With all the other agencies, which means doing it over a slightly longer time, frame,.

J

So I'd really counsel. Yes, as you say, let's do this,, but let's not run ahead of.

J

Everyone else and redesign everything in a way which makes assumptions.

J

About what our role in the overall system should be.

L

≫≫ Sorry just one other point which the regulatory governance committee has.

L

Discussed and which Eileen has touched, on,, the extent of which the.

L

Cqc should encourage, actively encourage employees or providers to.

L

Come to us,, it was interesting, and there wasn't,. Actually it wasn't described in.

L

Any detail, but I think in the inspection report on the Royal London hospital,.

L

It said that three whistleblowers actually approached, or three -- well, three.

L

Whistleblowers approached the inspection, team, I thought that was a.

L

Very interesting point and whether that's something which happens regularly.

L

During inspections wasn't so clear,, but it may just have been pointed out,.

L

Because of the person who wrote this particular report,, but it would be.

L

Interesting to know what sort of issues these whistleblowers did raise.

I

≫≫ I can't specifically remember for that report,, but it is just worth pointing out.

I

That, with the Colchester issue, it was a whistleblower at the time of Bruce.

I

Keogh's review that highlighted the problem with recording of waiting times.

I

And that led the CQC to inspect. Specifically on that point and to.

I

Investigate it, which then ultimately led to Colchester being put into special.

I

Measures,, it's not unique that it happened at one hospital.

I

I think I should take that one away and actually we ought to look into it,.

I

I'm not aware of it, happening.

I

I think what is a whistleblower?.

I

There are concerns raised, if you've got a focus group of 26 consultants in a.

I

Room and every one of them raises concerns,, which in some places they do,.

I

Are they all whistleblowers or just informing us about? What's going on in the hospital?.

I

So there is a difficult balance.

G

≫≫ A, tiny, point, I totally agree. We need to improve the linkages. I just want to say.

G

Most of us who went to Newcastle and sat in on the phone conversations were really impressed and I think the staff I met are doing a really good job and it's a.

G

Difficult job to do, I want to say that in case anyone gets the impression that.

G

They're not,, it's not -- they're doing a good job. It's a question of where the.

G

Information that they're getting goes, isn't it?.

A

≫≫ The last chapter not being written again, in a sense,. Where do they end up?.

B

≫≫ I think if I may David that will be really well received. Camilla in Newcastle.

B

Who I think have done a fantastic job to raise CQC's game in this respect.

B

I think the issue is our definitions,, so it's not just a short and medium term thing,.

B

I think there is something in between I, which I hope the RGB will help us on,.

B

Mike picks up that point,, a whistleblower legally has claimed the support of.

B

The employer, under the legislation and I think we need to respect that and listen.

B

To all whistleblowers,, it's a really tricky issue about whether we should believe.

B

All whistleblowers, many whistleblowers would say we need to believe them.

B

I would say the argument is, is it believe or is it listen?.

B

My personal view is, we need to listen to them.

B

But. There is a lot more people that are going to raise concerns, I think we need.

B

To be much more forensic in our policy developments and then in the delivery of.

B

Our practice about just distinguishing things which come in as a.

B

Whistleblowing concern because people want the protection of the legislation,.

B

The anonymity that can be afforded through that, and people who are quite.

B

Happy to say, I'm person X in this organisation, I've been trying to raise.

B

This issue for years, I've got absolutely nowhere, I'm prepared to go on the.

B

Record, I want to raise a concern.

B

Going straight through to people that are making safeguards, referrals, which will.

B

Mean it will get quite confusing between what does a local authority have to do in.

B

Terms of their actions,, what do we have to do? And I? Think that's the bit that we.

B

Are challenged on, from the kind of experience that's come through and.

B

Whether we're tracking each of those with precision,, because the difference.

B

Between something as a concern that drives an inspection and a very.

B

Formalised procedure for a safeguarding concern,, which would go into a local.

B

Authority,, which would get a whole architecture rolling into operation,.

B

Of what needs to happen at a local level, is really the point that we need to be.

B

Clear of,, so those colleagues in the NCSC are doing that triage at the.

B

Front-End need our help on those definitions, so they can get the triage.

B

Right,, that's the thing raised out of the data,, but once we've done that our track.

B

And trace system needs to support the definitions, at the minute. It feels a bit.

B

Amorphus of what comes in,, it's almost anything that comes into the phone line.

B

Is defined as a concern rather than the triage assesses them and then in a.

B

Sense catalogues, defines them,, does an initial catalogue, definition of it, which.

B

Then triggers what will be slightly different action for each of those, but the.

B

Gap in our procedures at the minute,, our practice is: we've not logged. What the.

B

Outcome is them all and that's the thing that needs to be put immediately right. So.

B

We'll put that immediately right from next week, that there must be a mandatory.

B

Field that doesn't allow any of those to continue into the system,, so we've.

B

Stopped that happening, we'll look at the 3,000, where we're not clear and that will.

B

Be the audit,, but the longer term piece of work is a clarity of definition,, sorry to.

B

Labour, it David,, but I just want to be clear what I'm saying, I don't want. It.

B

Being misconstrued in an open session that -- I don't want board members not to be clear.

F

≫≫ Just to -- a helpful input to that,, maybe work that Bill Hodson,.

F

Our national professional advisor on social care, has been doing with the.

F

Local Government Association and others around defining roles and responsibilities around safeguarding which will be coming to the executive.

F

Team shortly,, so there has been some pre-existing thinking that might help with that as well.

E

≫≫ I think David. Sorry I don't want to prolong it too much,, but can I at some.

E

Point could explain to me who takes responsibility for these?.

E

Because at the moment, we have a system where the alert goes to an.

E

Inspector, who is a generic inspector,? This is the old system, generic inspector.

E

Who has a portfolio of providers and they have to exercise continuous oversight,.

E

Surveillance,, as well as the monitoring system, of their portfolio,, now I, don't.

E

Understand- and there is no reason in a sense why I should have that.

E

Understanding automatically, in the new system, where we have specialist teams.

E

Who go and inspect something,? Who holds the residual oversight judgment of.

E

An alert coming in and deciding whether to do something about it?.

B

≫≫ It will be the same John,. It will still go to the inspectors,. So the issue, though I.

B

Think is once we've got these definitions. Sorted, is, what's the.

B

Managerial oversight to that,, but we still expect an inspector to have a.

B

Relationship with those people within their case loads, but I, think what we.

B

Need to be is much clearer about what the role of the manager is to support.

B

Those and one of the advantages of having more resource and more staff is.

B

That some of these big management ratios we've had where some managers.

B

Have had 20 inspectors that they're overseeing, we're shrinking those down.

B

So there can be a greater support and oversight from the managers to.

B

Those practitioners,- you can argue that some of these things were delegated too.

B

Low in the organisation and that people have felt unsupported with that.

B

Delegation, and the debates we've had here about the structure and the.

B

Numbers,, which we've touched on,, have we got enough staff to do thematic work.

B

Is to ensure that staff are supported by their managers,. Yes, there is an.

B

Accountability to the managers, but they need supporting.

B

Because. A number of these are desperately difficult,, so the decision on.

B

Following up the whistleblowers at Alderhey was one that me and Mike.

B

Took, we'd even taken it away from the regional director,, their managers and.

B

The inspectors,, we said sorry, it needs to take place and it needs to happen before.

B

Christmas; I know that's tough guys, but I want in you before Christmas, so 22nd.

B

And 23rd of December they were in doing the inspection..

B

They would have preferred not to do it, and we said you need to do it,, so I think.

B

We need to flex this on the delegations, depending on what the significance of.

B

The issue is that we're dealing with, and that's what we need to make clearer.

B

Than it has been,, because it feels a bit intuitive at the minute, rather than set out clearly.

A

≫≫ It is intuitive at the moment, which is why I think this policy paper from Paul is.

A

Very important,, precisely for that issue.

A

Steve, unless you are desperate to say, something?.

M

≫≫ I am, because we haven't talked about primary care and it's my duty to.

M

Raise that, and so we're starting to get an increasing number of people who are.

M

Raising concerns about general medical practice particularly, the ones we've had.

M

Recently, in single-handed, practices.

M

And we've had a few of these, the problem in a single-handed, GP practice.

M

Is often the owner,, the registered manager, is the GP and another family.

M

Member might be the nurse or the practice manager and therefore, if people.

M

Raise concerns in a very small entity like that,, it's actually quite difficult for us to.

M

Say are they a whistleblower, what's the effect of that person within an.

M

Organisation,, David and I have been having conversations about this because.

M

They have either triggered visits or a visit,. An inspection has triggered more.

M

Concerns from a member of staff who now finds a way of expressing.

M

Themselves,- and these can be quite serious- and it's quite difficult, then, for.

M

Our inspectors to write a report with information and also very difficult for us.

M

Sometimes, to defend ourselves when we're making a decision, so we're.

M

Finding it a very sharp learning curve in general medical practice,, and we do.

M

Need to sort out this hand off so that people are taken seriously and the taxonomy would be really helpful and we need that information,, because.

M

In some small GP surgeries,, if you go on NHS, Choices and other patient.

M

Evaluation websites,, they might have five stars and everything is wonderful.

M

From two or three patients,, but actually when you talk to some of the staff in.

M

Confidence, they're worried about quality or cleanliness or whatever, I won't go.

M

Into detail,, but you can see what we're looking at and that's why I wanted to say.

M

Something, I apologise.

A

≫≫ Michael, it's a big issue,, difficult and complex, and very nuanced this,.

A

We do need to pull it together at some point.

A

But in the meantime, Paul I think that policy you've got there will be really.

A

Helpful from the board's governance point of view.

A

And we'll put together a submission to the Health Select Committee, which we'll.

A

Circulate to the RGB committee beforehand.

A

Right,, thank you for that. That was a helpful discussion. Anna, Healthwatch?.

J

≫≫ I'll take any questions.

A

≫≫ Right the board forward: plan, I, don't think we need to discuss that. Do we Eileen?.

J

≫≫ Can I just ask, though, that the board forward plan gets filled in more fully.

J

Because there are a number of things that we've come back to again and again.

J

Which is really boring for everyone,, but it's because we haven't recorded.

J

Them as coming forward at a particular time.

A

≫≫ We're going to have a complete relook at the board and how it's used.

A

Properly and more effectively from going ahead from April, I think there are.

A

A number of improvements that we can make, can we pick that up in that context?.

A

A

Any other business, David?.

B

≫≫ So any other business, between 9 o'clock this morning and quarter past.

B

12, Dr Janet Williamson,, a currently director of NHS IQ, has told her.

B

Organisation that she is our, or Steve's third, deputy chief inspector,, so it's.

B

Janet Williamson that will join us to work with Steve as deputy chief.

B

Inspector covering the midlands.

B

So, that's Andrea with three deputy chief inspectors, Steve with three and Mike.

B

With a full set of four, so we've got two more to recruit,. That's good news and.

B

I'm pleased she's now just done the clearances and we've done the due diligence.

M

≫≫ Just to be clear as well. She'll, also be the national lead for dentistry,.

M

And we'll have a dental advisor working with her, I think that's important for the.

M

Dental sector to be aware.

A

≫≫ Any other business, no?

A

Any questions from the floor?.

A

E

≫≫ I just want to come back to the question of consistency of inspection,.

E

I'm, a user of GP services and perhaps rather closer to being a user of some of.

E

The other services than some members around the table!.

E

I'm worried about consistency, because what I want is for you to make.

E

A difference, as David was saying earlier: on, I really don't care whether you're.

E

Making a difference in services: I, don't use,. Consistency is fine. If all things are.

E

Equal,, but the danger it seems to me with consistency, is that you will say,.

E

Shall we say that you will not go into a care home in the middle of the night.

E

Because a care home with similar level of adequacy wasn't visited in the night,.

E

That sort of thing.

E

So that really worries me about that,, the only -- so really I. Ask you what you feel.

E

About, that you should take this sort of, the user's point of view into.

E

Consideration,, because one of the best things I think about it,, the new CQC is.

E

The way that you put the user first.

E

The only kind of consistencies that I really would like is, if all providers, at least.

E

In the social care, section should understand that the CQC will look with a.

E

Benign eye on the installation of video monitoring.

E

Finally, I wanted say that in Westminster, which is my area,, the links.

E

Between the CQC and Local Healthwatch are not as good,.

E

We are not receiving the reports consistently from CQC inspections,.

E

I wonder if something can be done to improve that?.

E

Finally, going to cross system thematic inspections, can Westminster be the.

E

First, place to have one?.

A

≫≫ David thanks very much, Andrea. Do you want to respond or pick it up outside the meeting?.

F

≫≫ No I'm happy to respond and pick up the points, and thank you very much.

F

David,, essentially, what you're asking is, what does consistency mean,.

F

I think what consistency really means is: are we --? Can we be robust about the.

F

Judgments that we make and so that, if we're looking at a service in one part of.

F

The country and we're looking at another part, same service in another part of the.

F

Country, we've got the --. We can be assured that a similar judgment should be reached.

F

It doesn't mean that every step of the way to get to that judgment has to be.

F

Exactly the same. So, if we go back to the point that you quite rightly made, which is, we are here.

F

To be on the side of people who are using services, and to be as diligent as.

F

We can be to make the right and proper judgment, if actually, that means that we.

F

Need to actually visit the service at a different time, or we need to expand the.

F

Time that we spend doing the inspection, because we want to look at something in.

F

More detail,, whatever it may be,, then we'll have the flexibility to do that,. But it's.

F

About getting,, using all those different inputs to get to a consistency of.

F

Judgment, I hope that's helpful.

F

As. You know we are developing a policy position around the use of surveillance.

F

And we'll be in the next few months and it's just taking time to set up, but doing a.

F

Round table looking at the use of cameras and what is happening in care.

F

Services,, and it may well also be things that Steve and Mike are thinking about as well.

F

So I can't give you any guarantee about that one now,, but you know that we're.

F

Actively, looking at it. And I can't talk about whether we'll be going to Westminster, first or not,.

F

But I'll leave that to others.

A

≫≫ Anyone else want to raise an issue?.

G

≫≫ Thank you Chairman,, can I just express my thanks to the board for.

G

Taking questions and for including them in the minutes of the meeting.

G

I have actually two questions if I could bring one first which follows the recent.

G

Conversation about input to the board's information, services, I'm from.

G

Hertfordshire- and there are many patients in Hertfordshire,.

G

Many cancer patients and lots of other patients who are not receiving clinic.

G

Appointments from their hospital.

G

If, a patient reports, either via the website or via the phone line that concern,.

G

Firstly, is there a different pathway for the two avenues?.

G

And at the moment, what happens next?.

G

And, how long does it take for anything to happen? Next?.

A

≫≫ Good question. Mike. Do you want to answer that?.

I

≫≫ I think the first thing is: if somebody is not getting an appointment,, have they.

I

Raised that with the Trust itself?

I

Because, that is the appropriate first channel,. If they've tried their best to get.

I

An appointment through the Trust and they've not received anything,. We should.

I

Then certainly raise that and again as inline with the discussion we've.

I

Already had this morning, we should make sure that our relevant inspection.

I

People on the ground are aware of this,. They can then make contact with the.

I

Trust and find out more about it, and if we need to do an inspection, we will,.

I

But it may be just a question of getting in touch with the Trust management.

G

≫≫ Thank you. The other question relates to inspection of hospitals and the listening events,.

G

I attended a listening event for UCLH, which I found very helpful,.

G

Very constructive, and the opportunity to have a confidential conversation very.

G

Helpful,, which I took advantage of.

G

Is there, an avenue for feeding back to patients from the inspecting team, their outcomes?.

A

≫≫ That's a really important point. Actually Mike,. We've discussed this with.

A

Ofsted the way they feedback to parents and schools and children, indeed, Mike?.

I

≫≫ We certainly haven't as yet got a process for feeding back to individual.

I

People who have come to those listening, events, I would hope that the concerns.

I

That are raised at those listening. Events would then be reflected in the overall.

I

Report on the Trust,, not necessarily individually,, but we heard concerns.

I

About people not getting appointments for out-patients, let's say or whatever it.

I

May be,, then, what did we find about? That would also be in the report,, because we.

I

Would have -- out-patients happens to be an area that we look at as a core.

I

Service,, we would have probed that further with the out-patient managers or whoever.

I

So we can take this away and think about how we can best do it,, but I think.

I

At the moment, I would hope it would be reflected in our overall report,, but if it.

I

Hasn't been,, maybe you and I can have a word outside the meeting about what.

I

Didn't happen or might have happened, better.

J

≫≫ There is a little bit of a theme, I think in a couple of questions that have been.

J

Asked from you both, which is the extent to which we expect people to find this.

J

Information on our website and as it were, pull it, and the extent to which it's.

J

Made easily available and pushed to people who might want to know.

J

So I think the question really is,. If I've been to a listening event, will someone.

J

Simply send the relevant report to everyone who has been to that listening.

J

Event, whose contact details we could collect at the listening event, such that.

J

They know as a matter of course, rather than expecting them to notice. It's been.

J

Published and go to the website. By. The same token, I think the thing about Local, Healthwatch and inspection.

J

Reports; I, don't honestly know what the policy is here,. The CQC's policy is here,.

J

But they're all available on the website, but do we expect Local Healthwatch to.

J

Always look before they go in to anywhere, for instance, to do enter and.

J

View or do a piece of work, to see whether there has been a report or do we automatically as an organisation, send relevant inspection reports to the.

J

Local Healthwatch in that area?.

J

So, it's a kind of activity here, perhaps, thinking about how we get the.

J

Information to the right people in a timely fashion.

I

≫≫ Anna, useful comments.

I

First of all in reverse order.

I

Healthwatch, Local Healthwatch should of course be at the quality summit and.

I

Will therefore have heard directly about what was found at the inspection and.

I

Should undoubtedly get the report,, but they will be hearing it first hand if you like.

I

I think we should take away your idea of at each of the listening events getting a.

I

List of particularly e-mail addresses of people who want to get copies of the.

I

Report,, if we can take that away to our design and delivery board, I think the.

I

Answer will be yes.

J

≫≫ I think the specific example that David was mentioning actually is social.

J

Care,, which means it's not in the new system,, it's still part of the old system,.

J

So you're right about Local, Healthwatch and hospitals I, take that entirely, but I.

J

Think it's a wider question.

F

≫≫ I have written myself down an action point.

A

≫≫ Good, thank you very much for those questions, I think we're going to break for lunch. Now,. Can we start again at 1 o'clock, please, 35, minutes?.

A

Thanks very much. Subtitles by Premier Captioning &, Realtime, Ltd. www.pcr.ie.