Care Quality Commission Board meetings, 19 Mar 2014

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From YouTube: CQC Board Meeting 19 March 2014

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

1. Apologies and declarations of interest 0:01

2. Matters arising and action log 0:27

3. Minutes of the meeting held on 19 February 2014 0:34

4. Chief Executive's report 0:39

5. Evaluation of Wave 1 and 2 inspections -- interim report 21:14

6. Chief Inspector of Adult Social Care update 1:38:10

7. Chief Inspector of General Practice update 1:38:10

8. Chief Inspector of Hospitals update 1:38:10

9. Appeals Policy 1:57:51

10.Thematic topics -- for agreement 2:42:41

11. Development of monitoring component for Adult Social Care, Primary Medical Services, Mental Health and Community providers 3:15:48

12. Fees 2014/15 for sign-off 3:26:04

13. CQC Business Plan and Corporate KPIs 2014/15 3:35:02

14. Monthly Corporate Performance Report 3:37:57

15. NIGC: 3:43:41

A. Terms of reference and approval of Chair

B. Report from meeting held 4 March 2014

16. ACG report (verbal) 3:47:41

17. Any other business 3:56:28

18.Questions from the floor 3:56:32

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

A

≫≫ Because, it will be a long meeting,. Can we assume that we've read all the.

A

Reports and just take questions on the chief inspector's reports?.

A

Steve is that all right? (Laughter).

B

≫≫ We can take a hint!.

A

≫≫ I don't think there is any matters arising that aren't covered in the agenda,. If there are perhaps we can come back to them at the end.

A

So, could we go,? Are we happy with the minutes, everyone happy with the.

A

Minutes of the last meeting?

A

Good thank you. David. Can we go to your report? Please.

C

≫≫ Good morning, everybody, I'll take the hint as well.

C

So on the first report that came around, there were eight items and on.

C

The supplementary report, you got an additional three.

C

I think the first three items, signposting, roadmap and update on transformation.

C

Are really about the transformation programme,? There is further.

C

Opportunities during the course of today for a conversation about this, John chaired a meeting yesterday, which actually gave a fairly in.

C

Depth review I, know he'll report later in relation to this,, so I'll steer clear of those things.

C

But. The first item is about signposting documents and handbooks.

C

Two signposting documents; you've seen these previously, have gone out.

C

Saying effectively to acute healthcare and ambulances, this is how we're.

C

Proposing to carry forward the inspection of your services and sending.

C

A signal to them and they can begin to think their way into that space.

C

But critically, we'll also publish provider handbooks.

C

There is eight that we're proposing to publish in early April, they're out for.

C

Consultation,, it runs from April to June.

C

They will then be revised in the light of those comments and published again in.

C

September with a view to being good to go for the October change to the.

C

Regulations that we also anticipate coming into force on the 1st of October,.

C

So that's beginning to align the new methodology with the new regulations.

C

And legislation, that is sending a signal to both services.

C

There will be similar handbooks for our staff.

C

So important documents, giving a steer both to our staff and to the system.

C

Allied to that is the roadmap; later in today's agenda. You are being asked to.

C

Agree as a board the business plan,, we wanted to wrap a narrative around the.

C

Business plan,, which is saying how that business plan relates to the two-year.

C

Roadmap, if you wish, what --? Why we're changing,? What improvements.

C

We're making and how we're organising ourselves to actually deliver those.

C

Changes and what are some of the critical issues,? That's the purpose of the.

C

Roadmap,, it will be a narrative which will explain what we do.

C

I've mentioned the update on transformation, I'll, not present, each.

C

Paragraph of this report chair,, but effectively what we're doing is just.

C

Outlining the progress we've made over the past few weeks,, that's bringing in.

C

The new regulatory approach,, the changes to the way that we're.

C

Organised, we've begun the recruitment of additional staff and managers, we're.

C

Beginning to put in place the training for our current staff that will be delivering.

C

The new methodologies, and we've also been doing an important piece of work.

C

Which is saying all outstanding issues: around enforcement or complaints.

C

Investigation must be handed from a current member of staff to a member of.

C

Staff on the transition on the 1st of April.

C

You can't just get up and walk away from the portfolio that you've got,.

C

You must hand it on to somebody else,, and there must be a positive hand over.

C

Is really the risk we're attempting to mitigate.

C

The risk we're attempting to mitigate is complaints, go unattended, to,.

C

Issues around safeguarding are left hanging between people,, so Hilary has.

C

Been overseeing a major piece of work,, those paragraphs are about that.

C

Pulse survey,, we do a major survey, each July of all of our staff and each.

C

February,, the past two Februarys anyway, we've carried out a pulse survey.

C

Which is 25% of the staff.

C

What I'm reporting on here you'll get more detail on this in due course,.

C

Is the initial results of the Pulse survey.

C

On page 4, we had a response rate of 81 percent,. It was a random sample.

C

Selected by GFK of 25% of our workforce, I think 691 from memory.

C

And, the top five scores we've set out in this note about improvements in our.

C

Colleagues, agreeing that we are going in the right direction, that we're clear about.

C

Why we exist and what we're doing and the support of the staff, 86 percent.

C

Positive,, a 12 percent increase, for the future direction of the organisation.

C

Significant improvements, I'm, always slightly wary of large scale. Changes,.

C

But we've, the largest increase, is 20 percent increase in staff reporting that.

C

They feel proud to work for CQC, which has gone up from 57 to 77 percent.

C

And also significant increases of 12 percent of people recommending CQC.

C

As a good place to work, up 12 percent from 53 to 65.,.

C

The lowest five scores are around communication, morale,, whether.

C

Change is being effectively managed, whether people feel valued and the.

C

Issue about accessibility of culture.

C

They all show an increase,. They are all movements in the right direction. With the.

C

Exception of communication.

C

I'm very pleased with these scores chair,, because I think this was a poll taking.

C

Place of around 1,300 people who had anxiety and uncertainty of selecting a.

C

Preference for a role and I think it speaks well of the organisation and the.

C

Effort that has gone on.

C

I think it would be wrong to be complacent,. These are good.

C

Improvements, but they're still scores. We should be more ambitious about in.

C

Terms of staff satisfaction.

C

Interestingly, the very last paragraph is we asked people what would be the.

C

Three top factors that would help and support people to do the job,. It was.

C

About systems and processes, equipping people with the necessary.

C

Skills to do the work and improving people's work/life balance.

C

So much there to chew on as we move forward.

C

But really very, very good. There is an issue about what we're doing. Here, I think it's important that we.

C

Actually publish this work, that we are transparent about where we've made.

C

Improvements and where we've not made improvements.

C

Comments really about morale, come into this.

C

Interesting in this is that personal morale is good at 62 percent,.

C

It's gone up: 9 percent,, that's 6! Out of 10 of our staff. Their morale is good.

C

But, interestingly, though, morale is good in CQC,, so when they're speaking of.

C

Others, it's only 35 percent,, that's 11 percent increase,. We need to.

C

Understand and explore that, people feel good about themselves and their own.

C

Morale but less good about the organisation,. There is some significant.

C

Challenges in that and I think publishing it and having an open debate about it is.

C

The right way to go, rather than being slightly gentle about it,. We need to tackle.

C

This in a pretty upfront, way.

C

John, I think, in the audit committee has been through a number of fraud.

C

Investigations and I just wanted to draw attention to those,, but there is a fuller.

C

Report on the audit committee, which goes into these.

C

I want to draw attention to some further work. We've been doing on.

C

Whistleblowing, where I'm pleased to say we have been able to secure.

C

Dr Kim Holt's servics for a three-month secondment to CQC,, where she'll work.

C

Part-Time and help us develop our work that Michael Mire is leading on.

C

Whistleblowing, I think she'll add real value and challenge to the work. We're.

C

Doing and our thinking.

C

On registered managers, Chair, you'll, know as a board that we've had previous.

C

Discussions about taking action against those services where there is not a.

C

Registered manager. That work has progressed well,, but one of the issues that came out as that's.

C

Being delivered is some push back, more from dental practitioners than.

C

Other services,, but certainly from some other services as well,.

C

About the requirement to have a registered manager.

C

A number of them have pushed back on the basis that they didn't feel there had.

C

Been an adequate explanation from CQC of the requirement to have a.

C

Registered manager and where we were going to take action in relation to a fixed.

C

Penalty notice, there had not been a proactive approach to them. Setting out.

C

That that's what they were going to do. As. A consequence of the push back. Colleagues have reviewed the approach.

C

We have been taking and we have now changed and emphasised the.

C

Importance of a direct contact with dental practitioners,, either a visit or a.

C

Conversation with them and we'll write out to all dental practitioners and all.

C

Providers around the operation of that fixed penalty, notice.

C

That push back has resulted in letters from MPs, my calculation about.

C

Between half a dozen and a dozen,, but a number of contacts from dental.

C

Advisors, Steve has been speaking to the trade associations for dental.

C

Advisors, and as I say, a letter will go out in my name setting that out.

C

I don't know whether board members have been approached individually, I know, David, you've had letters,, so I hope that gives some explanation of.

C

Where we're up to.

C

The note that was sent around supplementary, since drafting the note,.

C

Chief Exec's Report, there were three pretty important publications that took place.

C

Firstly, the Dalton Williams Review,, David, Dalton and Professor Williams,.

C

The president of the Royal College of Surgeons, were asked by the Secretary.

C

Of State to carry out a review of the threshold for the duty of candour and.

C

The way that that will be taken forward.

C

They reported in the past few days,. Interestingly, they have gone for a new.

C

Definition of significant harm,, which is very similar to the report that we.

C

Considered when we debated the CQC position at a board meeting two or three meetings, ago.

C

What will now happen. Is the government will respond to that,?

C

We anticipate regulations will be required and those regulations will be consulted.

C

On in the ambition that they will be ready for October and then that's a regulatory.

C

Framework that we will be asked to operate within in relation to the duty of.

C

Candour, I have also flagged up in the report that the Think Local Act Personal.

C

Partnership,, we're asked by government to look at the application of the duty of candour to adult social care,, so not just into the NHS and we've highlighted that there.

C

I'll report again when the regulations are drafted and we have a sense of what we're dealing with.

C

The Lords have done some work on the Mental Capacity Act and they published.

C

A pretty hard hitting report, I have to say last week in relation to the operation of.

C

The Mental Capacity legislation,, many of the messages resonate with the ones.

C

That were in our annual report on Mental Capacity,. The language was slightly.

C

Different but the issues they were raising had resonance.

C

I'm not entirely sure how the government will respond to that,.

C

It was only published last week, so the government will need to take some time.

C

To digest that and respond to that,, but there will be implications from that.

C

Government response for us in the way that we move forward.

C

Then, the last thing David just to flag is the Pay Review Body report,, which.

C

Government clarified that the 1 percent for staff is applicable to CQC, there.

C

Won't be a prevention of doing that, but no increases for very senior managers.

C

Will apply to CQC,, so what we'll do is there will be a report prepared to go to.

C

The Remuneration Committee, which will set out how that can be taken, forward.

C

So, that's all I wanted to share with you, thanks Chair.

A

≫≫ Questions, Louis?.

D

≫≫ Thanks very much, David can I just ask you about the last thing you raised.

D

Which was the Mental Capacity Act report,, because you're right that the.

D

Implications are potentially very significant,, including for CQC in the.

D

Sense that the main recommendation was a new oversight body for the Mental.

D

Capacity Act, and the model was explicitly the old Mental Health Act.

D

Commission,, which is now merged,, was one of the merging organisations to form CQC.

D

I must say: I had some concerns about that, because what the rest of the.

D

Difficulty of the Mental Capacity Act has been in is about embedding it in the.

D

System so that people, practitioners across the health and social care field.

D

Understand it and use it and get what it's for, not just what it might limit people.

D

About but what it might allow for people.

D

And. The idea of setting up a new oversight body, separate from all the.

D

Other bodies that are around didn't sound like a recipe for integration into.

D

The system as a whole, and obviously one possibility, is that the oversight body.

D

Might have links with CQC,, it might even be CQC. Do you have any feel for.

D

Where that's heading?.

C

≫≫ No,, to the best of my knowledge, I'm, not sure that the department knew.

C

Exactly what the Lords committee were going to say: beforehand, I'm sure there was a courtesy extended at the time of publication,, but I don't think there has.

C

Been a bank of civil servants working on what the response is going to be.

C

So I think that's to play. For. I thought the wording was interesting,. They weren't specific about creating a.

C

New organisation,, they actually just said there needs to be an oversight. Body,.

C

So I've not done a textual analysis of it Louis, somebody needs to do that,.

C

I think there is an issue.

C

I think people that are responsible for running services need to take.

C

Responsibility for ensuring their staff have the knowledge and skills to deliver.

C

That,, that's what we were trying to say in our evidence to the committee,.

C

That the responsibility should be with professional organisations,.

C

Clinical leadership,, the employers of organisations,, to ensure that their staff.

C

Are aware and knowledgeable of what the legislation is.

C

In interviews when we published our report, media were saying this is a bad.

C

Thing, I was saying: actually the Mental Capacity Act and its ambition is a good.

C

Thing,, this is about stopping the woman who gets up at 4 o'clock in the morning.

C

In a care home, dressed in a nightie saying, I'm off to school, now,.

C

Is that actually they're helped and supported to be in the moment that.

C

They're in and not allowed to go out in minus 2 or 3 temperatures, because.

C

They're going to school because that's what they choose to do.

C

If, that was one of our family members I think we'd have a view about whether.

C

They were allowed to go out., So I think there is a deeply important issue that underpins this. That needs to be teased. Out.

C

I think the Lords, with their normal sagacity, applied themselves to this, but I.

C

Think there needs to be a debate about what it means we're going to do,. There.

C

Will be implications for us and we need to join in those conversations,.

C

But it's too early, Louis,. It was published last Wednesday or Thursday.

E

≫≫ Just to say the obvious,, which is the really good results from the Pulse.

E

Survey, congratulations,, considering also all the transformational change.

E

Going on,, that's really good news.

E

I just had a small question about the latest: intelligent monitoring information.

E

On acute and specialist Trusts that was published on the 13th of March,.

E

Was there much press interest in that?.

E

And also was there much consistency with our previous list?.

E

If, you remember, we had a conversation. I think Louis was at the heart of that,.

E

About the volatility of certain measures,, did our bands change a great deal with the second list?.

A

≫≫ Paul: do you want to have a crack at that?.

F

≫≫ Yes. So, there was certainly less media interest than there had been in the.

F

Previous publication, which I think is probably in part down to us spending.

F

More time engaging with Trusts, so Trusts knew it was coming,. They had a full two weeks to comment on the individual pieces of data,.

F

Made a number of changes as a result of that.

F

In terms of the similarity, from memory there was plot one against the other,.

F

There was something like 60 or just over 60% correlation Trust to Trust on band,.

F

The main reason why there were differences were changes in the indicators, rather than changes due to people's position within the same indicator..

F

There was one Trust, Northwest London Hospitals, that came into band one.

F

There were a number of hospitals that went down from relatively high risk right.

F

The way down to band five or six,, which, although it's not a judgment, is as much.

F

A good sign as anything that people are on top of the risks that they face.

A

≫≫ Did, you want to say anything about it from your own observations?.

E

≫≫ Other than this is developing, and the volatility is an issue. As we pointed.

E

Out before, I'm pleased there is less press interest, I, don't think we should.

E

Put too much weight on that publication compared to the inspections for obvious.

E

Reasons that Mike sets out in his reports.

G

≫≫ I think one of the things that we did in this publication was refer to the bands.

G

As priority bands for inspection,, which, because that's how we see it,.

G

This is not the judgment as Paul was saying,. This is helping us to know where.

G

We might go sooner rather than later.

G

As Paul was saying,, the changes aren't huge,, some have improved considerably.

G

It will be interesting to see why that is,, but on the whole there haven't been huge changes.

H

≫≫ Actually Jennifer's done it, I just wanted to say congratulations to the.

H

Staff team, I thought it was a great result,, excellent result.

B

≫≫ Yes I agree about the survey as well.

B

The point I had was about the handbooks, David said that they will be.

B

Very important documents and I wondered if they had been patient proofed?.

B

Because, we need to make sure that everything that we publish does actually.

B

Lead to patients having good outcomes,, better experiences.

B

So I know they're going out for consultation now,, so I wondered if there.

B

Was any particular consultation planned with patient or service user groups,.

B

Just to have a look at them and say this doesn't make sense from where I'm.

B

Sitting or --, you know in a very general sense?.

F

≫≫ Yes, absolutely. Part of the engagement process over the 8-week consultation will be with.

F

Patient groups,, that's alongside the co-production we've done across the.

F

Different sectors in the run-up to these documents.

A

≫≫ Good, David thanks. I'd, just like to say on the Pulse report, I think huge tribute to you. David actually,.

A

It's really tough to keep people engaged and motivated at a time of change and I.

A

Think you've done a fantastic job., Well done.

A

Right next item -- I've lost my agenda: now, evaluation of wave 1, -- Mike, that's you.

G

≫≫ I think my task here is to introduce Kieran Walsh, who has done the work,.

G

We were committed from the outset to evaluating wave 1 as we went along.

G

Wave 1 and 2, so that we can then bring the knowledge from that into our.

G

Programmes and as you will hear,, we already have done some of the,.

G

Made some of those changes, but maybe just hand over to Kieran,.

G

To give us an overview;, people have seen the paper,, but to give us a flavour.

I

≫≫ Thanks very much Mike,. If you're happy, David I was going to talk for five.

I

Or eight minutes and not to reproduce what's in the report, but to try and offer.

I

Some thoughts about what it says for future directions.

I

Many, thanks for the invitation by the way to come to the board today and for.

I

Asking us to do the research.

I

I did also want to say thank you to the staff from CQC right. The way from Mike.

I

And the heads of hospital inspection through all the inspection teams and.

I

People in hospitals who, in our research, we've taken up quite a bit of their time.

I

And they have been unfailingly helpful and thoughtful and very honest about.

I

How the new inspection model has been working in the acute sector.

I

It's signalled on the agenda as a final report, but this is an interim report for us,.

I

We're continuing to do some research and we'll report again at the end of May.

I

In broad terms,, the strong positives are, there was a universal sense of support.

I

For the direction of the new regulatory model,, I, don't think I've met anybody in.

I

This research, who doesn't think this is the right thing to do.

I

There is also near universal support from hospitals and inspection team.

I

Members we've interviewed, that the new model is a step change in terms of.

I

Rigour and credibility.

I

There is a widespread sense that the pace of its development has been.

I

Hugely challenging, but probably the right thing to do and we have been struck by.

I

How much those involved have been trying to do to develop the process as.

I

They go,, in other words, to embed some learnings as Mike said, as it progressed.

I

The three challenges: I think that emerge from the evaluations, so far, are cost,.

I

Consistency and impact,, so what the process costs and its resource use,.

I

The consistency of the process and of the judgments and ratings it involves,.

I

And what impact it will have on the quality of care and on quality improvement, I want to come back to those at the end.

I

Any inspection system like this, and I've spent time looking at other people's too,.

I

Is founded on three things.

I

The standards of care that you express, on the processes of inspection? You put.

I

In place and on the people who do it.

I

I thought it might be helpful to use those three headings. Just to summarise, some.

I

Of the things we found. On the standards of care, this is how you, as a regulator, express your expectations.

I

Of the organisations that you're regulating,, what you think they need to.

I

Do,, how you say what represents good or outstanding performance in safety,.

I

In maternity care for example, and it's important because that's not only used.

I

By hospitals to understand what they need to do,, it's the way you.

I

Communicate your requirements to them,, but also used by inspection teams.

I

In making the judgments and ratings that they reach and writing the narrative of their reports.

I

In the process at the moment, those standards are pretty much implicit,.

I

There are elements of the standards, if you like,, embedded in the key lines of.

I

Inquiry, in the data pack, in the choice of core service areas, which you're.

I

Focusing on the domains that have been defined, but a great deal is left to.

I

Professional judgment at the moment- and there are some areas, of course, that.

I

Aren't covered by those standards at present., I think looking forward. The challenge is to find a way of being more explicit.

I

About those expectations, and yet not foreclosing the space for professional.

I

Judgment and discretion in the way that inspectors understand and interpret those standards.

I

But I would suggest that there is going to be a need to move towards being.

I

Much clearer about the articulation of, in my example,. What represents.

I

Outstanding performance in safety in maternity, care.

I

I'm happy to pause as I go along or carry on.

J

≫≫ Can you give an example of that,. Can you be really, really explicit about what.

J

That would mean?.

I

≫≫ Those standards might be --. One approach to this would be to bring.

I

Together the people who have been involved in inspections, if I, take the example of maternity, care,, those involved in inspections and draw on their.

I

Experience of inspecting organisations and saying having inspected and looking.

I

Across our inspection so far,, how would we describe or articulate in more.

I

Detail at a core service area for maternity, those great descriptors of.

I

Outstanding, good, requires improvement and poor,, so that then an.

I

Issue like, for example, if I take a practical, example, issues to do with the.

I

Cleanliness of delivery rooms which have arisen in a number of inspections,.

I

Your inspectors have a common sense of where that fits into their interpretation.

I

Of the quality of care. Now, other inspectorates have ended up getting into a process in which they.

I

Develop more and more detailed standards as they try harder and harder.

I

To close off and articulate every potential area of debate.

I

I think that's something you will want I'm sure to avoid as I see from nods around the table.

I

But, there is a middle way between having joint commission style thousand.

I

Page handbooks of numbered standards, and the position at the.

I

Moment where it's quite hard to articulate to an organisation what.

I

Represents outstanding care in a particular area.

I

Does that help?

I

Shall I carry on the three areas and come back?.

I

So standards was one issue: I raised,. The second two were processes and people.

I

On processes,: this is the mechanisms by which you inspect, the processes of.

I

Data collection, data synthesis and interpretation, the tools and protocols.

I

That you use and the way you arrive at your narrative and rating.

I

There's more guidance in this area and it's interesting to see how that has.

I

Developed over the period of wave, 1 and 2 in the inspection, guide, data pack,.

I

Timetables for inspections, guidance on how to use things like interviews,.

I

Focus groups, and so on. But. Our observation of the process is, it's still largely inductive and pretty much.

I

Self directed by teams.

I

This is an are where we've seen, teams struggling with unstructured nature of.

I

The data that they deal with. So they've, had lots of information provided by Trusts and it's really.

I

Challenging for them to synthesise, interpret and use that data.

I

So I think in this area too. Our suggestion would be that you think the learning is.

I

That there is a need for greater structure or more use of frameworks to guide that.

I

Process and that might involve more structured inquiries of Trusts in advance.

I

Of inspections so that they populate a framework of data, rather than.

I

Providing, as they do at the moment, hundreds of documents with information.

I

That the inspection team then has to try and make sense of.

I

But also, then, more targetted forms of fieldwork driven by that data, and that I.

I

Think has been an ambition from the start that the data should drive the.

I

Fieldwork, in practice that's been really hard to do,, partly because some of the.

I

Data hasn't existed at the level of granularity. That's needed.

I

So in the second area, again, it's more structure to the process.

I

The third area, the people who do the inspection,. This is the CQC staff and.

I

The wider inspection team, other inspectorates I've talked to have said.

I

This is the really hard area to get right,. The people who do it are crucial.

I

And, they clearly have to combine a content, expertise in acute care,.

I

An understanding of regulatory process and not to be underestimated,.

I

Really strong interpersonal skills in enacting the process of inspection.

I

Several people have observed to me about the inspectors,. They are the public.

I

Face of the organisation, they're, the people, who, clinicians and leaders in.

I

Acute organisations will meet and by whose conduct they will judge the organisation.

I

Clearly, the pace of this programme has been a real challenge and it's been.

I

Logistics and timescales that have driven the selection of people to undertake.

I

Inspections- and it's been marked that the people we've interviewed have been.

I

Hugely enthusiastic about doing that, for all sorts of reasons,, but they have been.

I

Very willing to step up and be involved in inspections.

I

Moving forward I think the learning would be that there will have to be more.

I

Of a selection process,, which I think is already been enacted.,.

I

Also greater focus on training and qualifications,, so, in other words, can.

I

Somebody be put forward to be an inspector, but actually you judge as an.

I

Organisation, they don't have the skills to undertake the tasks required?.

I

And to do it, well, other inspectorates have found. People have to make some.

I

Kind of minimum commitment to taking on the task.

I

There are also issues to do with the way you then deploy those people,.

I

How, for example, you build and sustain teams in the inspectorate,, so you don't.

I

Simply ask people to inspect with people. They may not have met before, how you.

I

Appraise the performance of individual members of inspection teams and so on.

I

In conclusion,, that was all I, was going to say on the three areas,. It has been a.

I

Privilege to watch the process starting and really interesting and impressive to.

I

See the degree of change over a short space of time.

I

In those three areas of cost, consistency and impact, I think that changes to.

I

Embrace greater structure,, greater organisation of process and selectivity.

I

Around people might help to address the issues of cost in the process,, but I think.

I

The cost of inspecting £500 million turnover organisations is always going to be high.

I

And, you have to balance cost of inspection against cost of service.

I

Consistency is the area I suspect, you'll, have questions and debate about,.

I

Structure in standards and processes is probably essential to getting.

I

Consistency in ratings,, but there are other things we can talk about, that.

I

Might help to move towards consistency in the rating process.

I

And impact is the poor relation here in some ways,, because I've said almost.

I

Nothing about it,! So far we have very little data about it,. We've observed quality.

I

In some instances,, but not gone beyond, that.

I

I think the experience of others is that that's actually in the longer term,.

I

The medium and longer term,, the area where you want to focus some effort in.

I

Assuring yourself that the process of inspection yields worthwhile impact, but.

I

That's not something: we've touched, on., David, I'll, stop there,, I, hope, that's helpful..

A

≫≫ Mike: do you want to respond and give your observation before we open it up for a general chat?.

G

≫≫ My immediate response is I, think Kieran and his team have done an.

G

Incredibly, thoughtful and insightful piece of work,. They have actually been very.

G

Easy to work with,, as you know, these inspections are very large and you've.

G

Got lots and lots of people in a room,, but we, the inspectors, are out inspecting the.

G

Trust but we are being inspected if you like,, but they have made that completely.

G

Bearable at all, times., And I think in terms of the findings,, both the analysis of the key areas and the.

G

Findings, I just wholeheartedly agree and would say that I do think we are on the.

G

Case with each of the areas,, we are working towards the standards,.

G

This the work on what good looks like and I think when we come to the.

G

Provider handbooks, we will already be a step down that line,.

G

I'm not saying we will have got it completely: right.

G

And I tink that will go on over time,, but we're getting a lot closer to that..

G

I think partly we're now in a position where we can start working backwards.

G

By looking at what the reports looked like and actually saying, how should that.

G

Influence what we'll do in inspection and what we do before inspection, in order to.

G

Get reports that are consistent in particular, and we are already modifying.

G

Our process of inspection;, we are finding the data, packs extremely valuable, but.

G

We all know that they could go further,, particularly if they are organised by core.

G

Service, they will be used more by the inspection teams, if the relevant data is.

G

There for them to look at and inform their lines of inquiry.

G

We've slightly changed the timetables of inspection,, for example, we get the Chief.

G

Executive of the Trust to give us a presentation on our so-called Day 0,.

G

The training and planning day and that's valuable for getting people,.

G

At least to hear what the Chief Executive thinks about the context of the Trust,.

G

The challenges of the Trust, and indeed, what they're, proud of.

G

And again, the more that we can do, the focus groups early, because they are.

G

Really hypothesis, generating, and the interviews with senior management late.

G

In the process, because they are our probing,, when we've already got.

G

Information, I think that is something that we are changing as we go along,.

G

So we have changed the process of inspection.

G

People, I would agree with Kieran, is all important, I think we have been.

G

Extremely fortunate to be able to get the people we have had so far,, but we need.

G

To build up a bank of people who do this with minimum commitment, I think they.

G

Are there, the people we've had have tended to say when can I come back,.

G

Which is extremely good news,, but we need to do more thorough selection and.

G

Training and, of course, training of our own staff,. This is a very different process.

G

For them,, and particularly when it comes back to the standards of care,.

G

What does good look? Like?, That's, not something we have been really expecting them to look at in the.

G

Past,, so we need to train them in that,. That's where the interplay between the.

G

Clinical experts and the CQC inspectors will come in.

G

But we have already developed a conversion: training, programme,.

G

But we need to do more on that over time.

G

And. We need to combine the skills of inspectors who are really good at.

G

Ferreting out the things that need to be looked for with the clinicians, who are.

G

Sometimes good at looking at the big picture.

G

So, all of those things are in progress and very useful to have this report.

G

Against which we can then say are we doing the right things.

D

≫≫ I thought it was very interesting,. A good report, actually, very encouraging.

D

I want to ask about credibility among clinicians,, because last week I was.

D

Giving a talk to the Royal College of Psychiatrists, forensic section,, initially.

D

They asked me to give a talk about safety in mental health care, by the time they.

D

Produced the programme,, my talk was called "CQC friend or foe?".

D

And I think that goes to the heart of how clinicians view CQC,. Is it a friend or a foe?.

D

So the questions about credibility, and at the conference itself, people raised a.

D

Couple of things with me.

D

One of them is about the reliability issue,, so I suppose they were calling for.

D

Something that was reliable., Therefore, more structured and more standardised, but without --. This is my bit.

D

They didn't say this --, but without bunching ratings in the middle to such.

D

An extent they're very reliable but don't actually mean very much.

D

So, that's one thing. The second thing was seniority of inspectors,. They were in a very particular speciality,, where they didn't really think that even general psychiatrists could.

D

Properly inspect the speciality that they deliver and there is probably some truth in that.

D

Getting that specialist expertise they saw as key to credibility.

D

I have been on a number of inspections under the old system and I must say I.

D

Have been really impressed by the inspection teams and the, what they.

D

Bring, the expertise and astuteness they bring to inspections,, but turning that into.

D

Something which clinicians recognise will be important.

D

Then. The third thing is more difficult,, it's about fairness and bear in mind. This is in.

D

Mental health, where people feel they are historically disadvantaged in funding and.

D

Priority in the NHS, they felt, one of their main worries was that they would end.

D

Up carrying the can for the failings of other parts of the system.

D

So that their service might be rated down because their commissioners.

D

Don't care about mental health or because, historically, all the money is tied.

D

Up in elective surgery or something like that,, so there is an issue of fairness.

D

Which they were worried, about, clinical credibility is my question.

I

≫≫ I'll quickly respond, then Mike I'm sure will have a more considered view to offer.

I

I think the clinical credibility of clinical members of the team is hugely.

I

Important and that's partly about currency and their engagement in current practice.

I

It's currently about their place in the spectrum of the area, them being seen.

I

Not just as members of that speciality but leading members of that speciality.

I

But, it's also about their connection with the speciality itself.

I

You make the point that we live with an ever fragmenting set of specialities and.

I

Sub specialities,, even with the largest teams that CQC has managed to.

I

Assemble for the first two waves, it's not been possible to have people who cover.

I

Every speciality and sub speciality.

I

What is striking, is some team members I would suggest, are much better than.

I

Others at parleying their clinical expertise into other areas,. Unsurprisingly, it's.

I

Medical directors, perhaps who have the most experience of doing that and.

I

Are therefore able to act more as generalists, but I don't think you are ever.

I

Going to have teams where you manage to replicate every speciality or sub.

I

Speciality, but the fact that the people on the team are seen as clinically credible,.

I

Current and leaders of some kind in their speciality I think is really important..

G

≫≫ Just, to reassure you that the degree of specialism does come into this.

G

To take mental health inspections, which were clearly in their first wave at.

G

The moment,, by defining core services within mental health, we would have.

G

People who understand about forensic, looking at the forensic wards,, we would.

G

Have people who understand about eating disorders looking there,, we would have people who understand about cams looks at cams,, so we're not.

G

Expecting a general psychiatrist to do it, all, any more than we are in the acute.

G

Sector where, yes, indeed, I, think the medical director role is very valuable.

G

Because they can see across a span.

G

But having people that really know about A, &, E or intensive care or maternity is.

G

Also very important, and we do try to get that balance.

G

So, if one of our sub teams is looking at maternity and children, we would.

G

Probably want to have at least one person who was maternity, but that could.

G

Well, be a midwife,, a very senior midwife and perhaps a paediatrician alongside.

G

So, it all depends how big the teams get,, whether we have to have one of everything.

G

But I think it's getting that balance right and we will constantly review that.

E

≫≫ Thank you for a very good report, admirably pithy thank you.

E

I have a couple of points, wider point: first,. There is a very febrile atmosphere.

E

In the service at the moment, it seems chaotic, uncertain,, some people say its.

E

Akin to the eve of the First World War,, we know the Everest to climb, but.

E

Actually, the gun hasn't been shot. Yet.

E

And, it seems to me I, think, I put in an e-mail to you, David, the undercurrents.

E

Are definitely if there is a weighing scales, on one side, there is scrutiny and.

E

Clobber in the system and the other side is support, that the scrutiny and clobber.

E

Scales are far more weighted down than the support element, and we at the.

E

Moment I think are largely in the scrutiny, we're not clobber, but in the.

E

Scrutiny side of the balance, and I just noticed your statement here. Kieran.

E

Where you say unclear whether those represented at the summit and.

E

Subsequently responsible for holding the Trust to account were indeed.

E

Responsible for helping is unclear.

E

And at a meeting that I was with, with other ALB chiefs. Recently, I felt there.

E

Wasn't cohesive view necessarily in the system about where support should.

E

Come from and how people should link together the ALBs more generally.

E

So I think, while we're polishing our mirror,, the scrutiny, element, I really do.

E

Think we should be overtly working with others to think about how better that this.

E

Balance could be better corrected as we go. Forward, I think that's very important.

E

For us and for the system., So I think what is done after those summits with TDA and Monitor, who.

E

We're very used to clobbering, that's where they come: from, and NHS.

E

England,, what we do and how we can lead. That is an important point. I think.

E

I think that's the main point. I wanted to make.

E

On, the sub specialisation point,, the only link, I thought that could be useful here.

E

For us is all the efforts that are now going into perhaps developing the peer.

E

Review services in specialities and sub specialities and actually, if they could.

E

Only,, if some priorities of that initiative could be to get more information and.

E

Have this sub specialist scrutinise themselves before we arrive, then we.

E

Could rely on that without us having to go there in finer detail.

E

A

≫≫ Paul on Jennifer's, first point?.

K

≫≫ Since: this is to the board as much as to Kieran, because it's a.

K

Request for research mission creep really and about impact and outcomes.

K

And improvement, because you've actually been there at the quality.

K

Summits,, this is an area which is absolutely crucial to our work, but we're.

K

Not involved in at all,, but we're involved in the summits,, but the nature.

K

Of improvement is engaged, is other people's work.

K

It would be really --, I think my worry is, as a board,. We might start researching.

K

This in a couple of years time, which will be too late.

K

I think it would be very interesting to follow through a couple of post.

K

Inspection activities or non-activities for several months and to research what.

K

Happens, and just to see if it's picked up,, if we're ever referred to, once we're not.

K

There do we disappear from the world?. Those are the sorts of things I think would be really useful to know and if.

K

There is any form of improvement organisation- that's assisting,, because if.

K

This doesn't happen. We, as an organisation, have got real problems as.

K

Have all of the organisations we're inspecting.

A

≫≫ Just before we go back to Kieran and Mike, Paul, you wanted to pick up on.

A

Jennifer's last point on speciality ratings or speciality analysis. Before we go back to them.

F

≫≫ Yeah the point about using peer review and clinical audit.

F

When we put out the wave 1 report, which was very linked to, and in the.

F

Same space as the findings that Kieran has in his interim report,, this is one of.

F

The key pieces Mike highlighted was that providers themselves don't often know.

F

What the effectiveness of their service is, part of the way of getting into that is.

F

Going to be onsite inspection with specialists, but a serious part of it has.

F

Got to be the data from peer review and clinical audit so to endorse what you're saying Jennifer.

G

≫≫ Shall I make a start?

G

Can I pick up. One point: I didn't respond to Louis on which was the fairness in.

G

Carrying the can. Clearly, we are there largely on behalf of the patient, not on behalf of the provider.

G

Or the commissioner,, we need to say it as it is.

G

I think by saying it as it is, that will help a great deal and by being able to look.

G

Across from my position between mental health and the acute sector being able to.

G

Say is there a level playing field here, that will be very valuable,, so if patients.

G

Who are elderly and have dementia? Who could be either in an acute hospital or.

G

In a mental health facility, have we got a level playing field there in terms of the care provided?.

G

So I think we will be pointing out things that are uncomfortable in all the sectors.

G

That we look at and in some cases, when it comes to the quality summit,.

G

People will be undoubtedly saying yes, but that isn't commissioned, and so that.

G

Might be about people having to be moved a long way away to find a.

G

Psychiatric intensive care unit for example, those points we will be.

G

Exploring,, it may just be that there isn't one within a reasonable distance.

G

I think we will just say that, as it is when it comes out,, I hope that will contribute.

G

To fairness is my view.

G

In terms of the summit. I have now attended several summits.

G

You won't be surprised to hear that they differ depending on what we have found.

G

So, if we have found very good services throughout, they are largely a.

G

Celebration,, if we have found areas where there is a lot that requires.

G

Improvement, they are hard grind about who is going to be doing what.

G

But, we do have all the relevant people in the room for those summits,. We make a.

G

Presentation about what we found and I hope that by being clear about what we.

G

Found, that actually tells people really what needs to be done.

G

We have the Trust who then respond, but also the CCGs,, the local authorities,.

G

A wide range of others, Local, Healthwatch etcetera,, who will.

G

Comment, and actually the final part of the summit is a working meeting where.

G

People all say: okay, what do we need to do,? So if I take the Barts health summit.

G

Where we issued 15 compliance actions, one of the things people were doing at.

G

Different tables was working through. What are we going to do to resolve those.

G

15 compliance actions.

G

Of course we don't disappear afterwards,. We will go back and check.

G

Up on those compliance actions and any warning notices as well,, so we will be.

G

Coming back and they know, that.

G

We will have the opportunity over the next few months to at least look at the.

G

Keogh Trusts, which we are going to be reinspecting, I, know the methodology.

G

Was not entirely the same,, but we will be able to see to a certain degree what.

G

Action has transpired, as a result of that which I think I will also be useful,.

G

Following up on Paul's point about peer review and accreditation, absolutely,.

G

What we're doing is saying which of the accreditation and peer review.

G

Programmes can contribute usefully to what we're doing,. We are looking at.

G

Them in terms of what do they tell us about safety,, effectiveness,, caring,,.

G

Responsive, well-led for their areas,, but we already have things like the cancer.

G

Peer review, programmes, I, think the diagnostic programmes, at the moment.

G

We do not have radioology and pathology as core services,, but getting information.

G

In from their accreditation and peer review, programmes will be enormously.

G

Valuable and over time, we'll bring more in as well.

A

≫≫ Could, you pick up Paul's point about measuring the impact?.

I

≫≫ I think we are getting from this piece of work, some early information about.

I

Impact so we are just starting to survey individuals in the wave 2 NHS Trusts.

I

After the quality summit to gather some information about both their views of the.

I

Process of inspection and their engagement in it,, but also their views.

I

About the report,, so we're asking them questions about to what degree they.

I

Think the report has added to knowledge about the quality and performance of the.

I

Organisation,, but we're also asking them about early action planning,, but clearly.

I

That's about a week or two after the quality summit,, that's very early in the.

I

Process,, so I think it would be worth going back to Trusts in wave 1 fairly.

I

Soon, to ask the question of a number of stakeholders to what degree you can.

I

Trace through marker actions from the report to see them acted, on.

I

It is a challenge always for regulators to work out to what degree they want to.

I

Take responsibility for follow-up and improvement,. It is clearly not your job to.

I

Enact the improvement, but it is your job to see it. Enacted.

H

≫≫ So, just following on from that,, it seems to me that the third party, if you.

H

Like,, the collective third party- that's not so much in the report and I think it's the.

H

Way that it's been scoped and we've conceived of it, are all of those.

H

Organisations who operate at a local and community level, on whom we depend.

H

Quite heavily both for intelligence that goes into the process,, including the.

H

Public meetings and so on, plus many of them are going to be key players in at.

H

Least challenging, if not supporting to ensure that some change actually.

H

Happens once we've left, and there's not very much at all in here, I think that's.

H

Because it wasn't in the brief, but I think it would be really important and not.

H

Unrelated to the points about impact,, but either in your final report, if you can,.

H

Certainly, if we do any further reports on other, on the other inspection regimes,.

H

As they come, in. I think we really need to make sure we talk not just to the regulated community.

H

And to the people who are doing the inspections, but also to those third party.

H

Organisations,, because if they don't feel that they've been properly engaged and.

H

Involved from beginning to end,, they won't be involved in the end,. They won't.

H

Stick with it and play their part.

H

As, you say: that's not our responsibility,, but we can make it less likely to happen.

H

By the way that we engage or don't engage with those people.

H

In that I am thinking partly and parochially about Local Healthwatch,.

H

But not only Local Healthwatch. If, we find there are issues about particular pathways in a licensed entity.

H

Of some sort,, then we will want the help of local Mind or the local Diabetes UK or.

H

Whatever it is, to work on improvement.

H

So I think we need to be a bit more structured in our thinking about this.

H

Generally- and that means thinking about the three parties- not just the two.

H

Just to offer that one of the things that we're doing, thinking of doing at.

H

Healthwatch England over the next month is bringing together the Local.

H

Healthwatches in the areas where first wave inspections happened to get a bit.

H

Of a view about how they feel about that process, I know it will be very mixed.

H

We've talked about this before Mike. But. Hopefully that will give us a bit of local learning, but they're, not the only people in town.

A

≫≫ Thanks Anna,, rather than pick that up now can we just go to Steve and Kay.

A

And then take the three together.

L

≫≫ Thank you Chair, I thought. The report was very good and helpful.

L

I just wanted to say something from the primary care angle,, because this is a.

L

Paper focused on what we have been doing in acute,, but the work I have been.

L

Doing over a number of years, both on developing examination systems and.

L

Also, inspections for training, your findings, chime, really well with what.

L

We've discovered in primary care, as you would expect it to be.

L

So we'll take some of the lessons from there.. I wanted to say a couple of things. One was about improvement and the balance again, I think Jennifer's.

L

Point is really important: between; I wouldn't call it clobber, but certainly.

L

Scrutiny and demand versus quality improvement.

L

In our strap line, it's about encouraging improvement, isn't it in what we're doing.

L

But we're not the improvement, body.

L

In primary care,, GP land,. We don't have a Trust Development Authority and one.

L

Of my big concerns is who is going to support the improvement in primary.

L

Care when issues are identified, now on one hand, you could argue that GP.

L

Practices are independent contractors or increasingly chains or bigger groups, and.

L

They have a responsibility.

L

On the other hand, I think the State also has a responsibility through NHS.

L

England, of which they are not funded for that activity,, and so some work does.

L

Need to be done looking at the balance between the responsibility of the.

L

Contractor and NHS England, as the commissioner, and the relationship with.

L

-- I'm with Anna on this,, about how we use other groups to improve the care,.

L

So if you look at homeless care, the practices that are doing really.

L

Really well actively engage with local charities, housing associations and.

L

The national body homeless, link, and the best products, projects that have come.

L

Out recently have been co-productions of the third sector, primary and.

L

Secondary care, I think that Anna is a really important message on that.

L

I think looking at consistency, which we've talked about at the board,.

L

Frequently,, for me, that's the number one issue about how we ensure consistency.

L

Of decisions, judgements ratings, if you're in Cornwall or Central.

L

Birmingham,, whether you're in Tower, Hamlets or Newcastle.,.

L

And, the funding going into primary care does vary, even on a road it varies,.

L

Therefore, we will need to look at the context of the practice,, but the.

L

Judgements should be the same.

L

And. We've looked at, because we're behind Mike, thankfully on time,.

L

Investing right upfront on selection and training,, because we know from.

L

Examinations, that doctors in the surgery make judgements quickly based on.

L

Information confirmed on examination using investigations,. But when you put a.

L

Doctor into an examination or an inspection regime, they are not.

L

Necessarily as good as they are in the surgery,, therefore, there are hawks and.

L

Ducks and so initial training and feedback is going to be so important.

L

So, your paper is really helpful because it helps put weight behind what we're.

L

Trying to do, thank you.

B

≫≫ I agree, the report's very helpful and certainly chimes with what I saw when I.

B

Joined one of the inspections, and of course, from the outset, we were saying.

B

That we were learning through doing and we've learned a lot and done a lot.

B

I think the single most impressive thing for me was that everyone seems to.

B

Support the direction we're going in and what we're doing,.

B

So that's, really important.

B

My main issue was --. It may be because you weren't asked to look at it, but there.

B

Is not really anything in here about patient and public voice.

B

So, for example, I, don't know, if I just read, this, I wouldn't know how or if we --.

B

How we sought the voice of people who were using the services,, the patients,.

B

Because I know there were listening events and some talking to patients, but I.

B

Just don't know what was done really or how well it worked.

B

And also, the other other side of that is in terms of our experts by experience,.

B

I know they were part of all of the inspections, I think, but I'm not sure how.

B

Well, that worked or what their views were or --, and it would be useful to have.

B

That, at least in the future,, if not now.,.

A

≫≫ Could, you respond to those three points that have been made. Then I'll ask.

A

Michael just to say a few words after that, Andrea did you want to say.

A

Something as well?.

M

≫≫ Afterwards is fine.

G

≫≫ If I take Anna's and Kay's points together because I think they're, covering similar ground.

G

Clearly, incredibly important that we do hear the voice of the public, but also the.

G

Users of individual services and how we best do that.

G

As, you know: we've had the open public and patient listening events, we've also.

G

On top of that tried to go out in advance of those to particular local groups, to ask.

G

Them for their opinions,. We have always come to Local Healthwatch to ask them.

G

To give us information during the pre-inspection phase.

G

I think we can do better. We also have the survey data, and there's the CQC in-patient survey, which.

G

Gives us a broad picture of what patients are saying about that hospital in.

G

Comparison with others, that has the great advantage that it is robust across the country.

G

I think now, of course, very recently, we've got the maternity survey and we will.

G

Soon be having a children's survey as well,, so I think we are getting a more.

G

Robust picture related to different aspects of acute hospitals, but I think.

G

We need to think about. Could we go further than that?

G

So? Could we --? It would be at least theoretically possible, for example, to say.

G

To a Trust, can we have the names of people who have recently had children.

G

Or could they write out to the recent mothers, so we can specifically ask them.

G

To a focus group, or indeed to people who recently been bereaved, and we can.

G

Ask them what their experience has been.

G

So. There are different ways that we can develop this and see what works.

G

We do, of course, also have all sorts of other channels like e-mail and.

G

Correspondence- and we do make sure that the correspondence about a.

G

Particular Trust that we've had is collated as part of the pre-inspection.

G

Work so that we know, for example, whether there have been either.

G

Complaints or concerns, or indeed whistleblowing events.

G

So I think we do try to bring all that together.

G

I'm not saying we're doing it as well as we could,, but we're certainly very keen.

G

To make sure we do hear that voice. Anna.

H

≫≫ Sorry, just that's helpful and I, know that I'm sure there are improvements we.

H

Can make, Mike, but I'm not just talking about inputs, I'm talking about potential.

H

Value added of individuals in the community and organisations in the.

H

Community, who can make change happen by being involved in it? Afterwards.

H

It's something about not just thinking about engaging with the public as.

H

Helping improve our inspection regime, it's about engaging with the public and.

H

The organisations in the community, in order to help improvement, happen and.

H

That's a slightly different objective.

G

≫≫ It is,, but again, of course, technically the primary responsibility for that lies.

G

With the provider- and we have already seen some providers that are doing that.

G

Fantastically well and some that are doing it much less well.

H

≫≫ My only comment is I think the way we do the inspection and the way that.

H

We engage those organisations will have an impact on their willingness to help later.

H

So, it's not that we're responsible for it, but we can have a significant and.

H

Potentially detrimental impact on it, if we don't engage people in the right, way.

A

≫≫ On that point Camilla. You wanted to come in.

J

≫≫ Anna I think it would be helpful if you could say what you think Healthwatch's.

J

Role is in that and where you think Healthwatch can't do that,. Do you see.

J

What I mean,, because quite a lot of that would be great coming from you, wouldn't it?.

H

≫≫ I think Local Healthwatch can do some of that,, so certainly Local.

H

Healthwatch could help to direct CQC as it's building its inspection protocol to.

H

The right kind of other people to talk to in the local community.

H

So, it's a bit like an extension of the signposting and information role,. They.

H

Know who is active in the community at the community organisation level,.

H

Who could be useful inputs to this.

H

I, don't think they should be the conduit, then, for that conversation between CQC.

H

And those organisations. But CQC inspectors themselves are also locally very involved with those.

H

Organisations, so I don't think Local Healthwatch is the only source of information.

H

One of the very important things that needs to happen between now and the.

H

Final versions of the inspection regime is a clarification about what we can.

H

Usefully contribute without duplicating what other people do.

H

That's a two-way conversation because there's a question about capability and.

H

Resource at the Local Healthwatch level, as well, as,, which we would need to.

H

Support,, as well as what other people are able to contribute.

H

So, it's a good question Camilla,. In a way, I can't tell you the whole answer.

H

Because I don't think it's properly developed, but I think there is an important role for Local Healthwatch.

I

≫≫ Just comment briefly on the points that have been made, on Anna's point.

I

About engaging other organisations in a sense, the purpose and process of.

I

Regulation, there's clearly a big shared interest there with those other.

I

Organisations, and in reflecting on our research I, don't think we've had a very.

I

Good line of sight into how that's worked because we've been pretty focused on.

I

Observing the inspection process and I think it should be happening before the.

I

Inspection process and after the inspection,, so it's not been perhaps a part of the process we've seen easily.

I

But you're absolutely right, that regulators often co-opt those.

I

Organisations to their purposes of regulation or try and make regulation.

I

Serve those organisations' purposes and then they use your report. For example, in.

I

Leverage in local discussions- and they will only use it if they believe it, trust, it,.

I

Think it's credible and so on.

I

So I do think. That's important.

I

We have in this work interviewed experts by experience who are on.

I

Inspection teams and we've observed the patient to public engagement in.

I

Inspections,, for example, on listening events,, but we have a partial view of that.

I

Process from our research.

I

On Steve's point about improvement,. It's certainly true that small organisations.

I

Don't necessarily have the capacity to improve, large organisations, sometimes.

I

Also struggle with that capacity, but the point about GP practices, I suspect.

I

Applies also to single owner nursing homes and quite a lot of other.

I

Organisations that you regulate.

I

It does raise a question for me, which is to what degree the inspection tells you.

I

About not just the quality of care they provide,, but their capacity to improve,.

I

And so enables you to make a judegment about their likely future.

I

Trajectory,, are they an organisation that is going to remain at its current level of.

I

Performance because it's not capable of changing, and that's I, think a complex.

I

Question in relation to the acute Trusts that you've been inspecting as much as it is to smaller organisations, and it raises the question to what degree your.

I

Inspection process touches not just on the core service areas, but on more.

I

Corporate or organisational dimensions of performance, capacity to improve,.

I

Leadership and so on.

I

Steve's other point about consistency,. We are in our current piece of work.

I

Surveying CQC inspection team, members, staff, as well as clinicians, who.

I

Joined the teams and we're presenting them with a set of example, cases and.

I

Asking them to rate them,, so we will have some data about consistency.

I

And reliability and rating to feedback to you in our final report.

I

Kay's point about the patient to public voice. I think I've answered in talking.

I

About Anna's point, that we have interviewed experts by experience, observed public engagement, but perhaps not had as much sight on that.

I

As we'd like to have in retrospect.

A

≫≫ Michael.

N

≫≫ Just, a few points, I, also thought this was an excellent report and there was a.

N

Particular paragraph which I'll come back to in a moment which struck me as.

N

Crucial, I'm just trying to work out which page it's on, because the report is.

N

Not page numbered, but...

N

The Chairman, David and I, attended last night, a dinner organised.

N

By the Foundation Trust Network for about eight or nine, mostly chairmen of.

N

Hospitals that had been inspected, I think there was one or two CEOs,.

N

Now this was under some form of Chatham House rules,, so I'm not going.

N

To mention any individual hospitals.

N

But, the feedback to us was highly positive about virtually all aspects of the.

N

New inspection, process.

N

As I mentioned to Paul and Jennifer and Anna before we started, to some extent.

N

It's because of the, how poor the old inspection regime was, so they're.

N

Contrasting a previous way of inspecting,, which, from what they said, sounds truly.

N

Dreadful, to a vastly superior way of looking at hospitals.

N

And, so I think that we have to be careful that it was really encouraging to hear the.

N

Feedback,, but it was partly because the feedback was so positive because what.

N

Happened before was so poor.

N

But, having said all of that, the central pillars of the new process,.

N

And especially, the involvement of clinicians is the absolute key to both the.

N

Credibility with which the reports are seen,, but also to the impact of the.

N

Reports on making improvements, happen.

N

There was actually some concern that -- this was their terminology,, but I think the.

N

Board, we fall or I fall into it. Too,. There were actually still too many old style.

N

Inspectors on the inspections.

N

Now David quite rightly pulled up one of the chairmen around the table who had.

N

Made a remark about this to say: actually the inspector he was talking about was a.

N

Very good inspector,, but there was a general sense that in the inspection.

N

Teams there was now an even more noticeable difference in quality between.

N

The clinicians and some of the CQC inspectors.

N

The two main points: I think,, the two main learning points that came out,.

N

Certainly for me- and it will be very interesting to hear the Chairman and David; was first of all, some feeling that there was a disconnect between.

N

Intelligent monitoring and the data packs, and what actually went on during.

N

The inspection, that the inspection itself did not seem to be,, although, as I've said.

N

Almost unanimously, all of these chairmen found the inspections to be.

N

Extremely helpful and valuable.

N

They didn't see a strong enough connection between data evidence and.

N

What actually then went on during the inspection, or indeed in the reports.

N

Themselves, so I think this disconnect, or this perception of disconnect is.

N

Something I think CQC needs to work on, because it does trouble the Trust.

N

And indeed, I think it troubles them in a particular way,, which is that we may.

N

Have had a group of very good chairmen last night, I mean they were.

N

Very good- and it may have been that chairmen -- or chairpeople, who were.

N

More -- chairs, who are more critical of the process, didn't accept an invitation to.

N

Dinner, I don't know,, so there might have been a positive adverse selection.

N

Process going on,, but they clearly see our reports as very powerful leverage to.

N

Get change to happen., So, the quality of evidence and the connection with data and the ability to.

N

Prove is critical, for them, as well as for us,, because it affects our credibility.

N

The second point they made, and this really emerged throughout the evening.

N

In various shapes,, various parts of the discussion, is -- I. Think on page 7 of the.

N

Report, in the third paragraph, which begins "Inspection fieldwork"...,.

N

There clearly was a tension. Last night, I don't mean a tension in the negative.

N

Sense, but in an intellectual sense, between using intuition, judgment,.

N

Experience, induction and having a clear set of standards or a clear framework,.

N

As we were discussing earlier.

N

We just need to resolve this.

N

I, don't think -- I'm not going to discuss it any further.

N

I think Mike is completely aware of this. As I say, I thought. This paragraph was in.

N

A way the central paragraph of the whole report,, because we have to solve.

N

This, and as I say, it did come up in various guises over and over again.

N

Yesterday, and as we move into rating every hospital and indeed other types of.

N

Provider that the CQC regulates,, this balance between intuition and standards.

N

Will become increasingly important,, so I'll just leave that as a thought.

N

The final point: I think,. We did talk last night and the Trust raised this issue of.

N

The patient voice or the community voice.

N

They were actually not entirely convinced by the way the CQC was.

N

Doing this at the moment,, partly because the meetings at which, or the listening.

N

Meetings at which patient or public views were being held, ran the danger of.

N

Having another adverse selection problem that people who have.

N

Complaints would go to the meeting, people who were satisfied. Didn't,.

N

Or people that had serious complaints just weren't fit enough to go to the.

N

Meeting, and one of the chairmen actually made a point which I think Mike.

N

Was touching on,, there must be more --, he used the phrase more sophisticated.

N

Ways, to get input, now whether that means we can ask whether the CQC.

N

Itself does it,, although it then becomes another cost,, but using ugov surveys or.

N

Some sort of more statistically robust ways of getting the public and patient.

N

Views I think was in everybody's mind last night.

N

It may be that we can maybe ask the hospital to carry out this sort of ugov.

N

Survey and they are, almost by definition,, because if they can predict.

N

The results of a by-election with a sample size of a thousand they should.

N

Be able to do a pretty good job with a relatively small sample size for a.

N

Hospital or group of hospitals and various services.

N

So this is an important issue, but I think again from last night. It's very important.

N

That we have to have an amount of anecdote,, because I think stories are.

N

Important, but it is absolutely essential in everything the CQC produces and the.

N

Way it consults the public and in all of these aspects, that they truly are based.

N

On evidence and sufficient evidence that the professional judgement can be seen to be robust.

N

So as I say,, when the three of us left, walked out together, we were slightly.

N

Overwhelmed by how positive the dinner had been.

N

So these suggestions come in the back ground of a group of chairmen.

N

Who found this process to be, by and large, hugely helpful,, effective and.

N

Incidentally, the last question that came up was: will the inspection make a.

N

Difference, a positive difference to how good your hospitals, are?.

N

And again, we went around the table and every one of the chairmen, or chairs,.

N

Said yes, they will make --. The report on us will make a difference to the quality.

N

Of service we provide.

N

So I, hope that's useful feedback on the dinner without crossing this Chatham.

N

House line,, whatever it is.

A

≫≫ Thanks Michael. I thought what I'll do is probably circulate a note that I made.

A

Which takes really Michael's point and adds to it a bit.

A

Time is getting on, Camilla. You wanted to jump in something quickly,, then Mike.

A

And Andrea and we must move on.

J

≫≫ Just on the ugov point,, we commission ugov every week,.

J

They don't always predict by-elections, the most powerful way of predicting.

J

Anything is crowd, sourcing.,.

J

The friends and family test I would imagine, does about as well as a ugov.

J

Poll would,, I guess. What maybe we need is something that's more specific than.

J

Friends and family, so FFT gives you a generalised picture of a feeling about.

J

A hospital,, presumably Mike, you are wanting to get slightly below that level,.

J

This is a question really to think about,. Whether friends and family gives us,.

J

Whether we're able to unpack that to a deeper level, but I wouldn't endorse.

J

Going around with a new set of polls.

J

Can I just come back to Kieran very quickly on the point about capacity,.

J

Because we've discussed this before,, obviously, improvement is very.

J

Important to us, we're not in control of it, but we have to be cognisant of whether.

J

An organisation has the capacity. I had a meeting recently with the chairman of a hospital which I won't.

J

Name, made this point to him, because his particular hospital has serious.

J

Financial difficulties and it's the point Michael made about the leverage,.

J

He said, for goodness, sake, do not use our difficulties as an excuse to prevent.

J

Us from improving, CQC is the most effective lead that we will have to push.

J

Through the changes we need to make. I just think that's quite important to be cognisant. Of., He and his board do not want us to let them off the hook, because we are the.

J

People who he can use to make the change.

J

And, the final point I wanted to ask anyway, was just to check, Michael put.

J

Very well the tension that we're all aware of between. What's intuitive and.

J

What's -- what's judgement and what's explicit; I just wondered Kieran if you.

J

Could be clear on whether your next report will make any actual recommendations on that, or is that something that Mike and Paul will just.

J

Figure out in due course?.

A

≫≫ Before you answer that I'll. Let you both wrap up this session,.

A

Anna, can you be really quick.

H

≫≫ Sorry I just want to be clear,, I. Think we're talking about two different things.

H

I'd like us to do both, and we have talked about some of this before.

H

One is I, think the conversation and feedback from the dinner adds to it,.

H

We really do need to have a discussion at the board about the process for public.

H

And user involvement and engagement in the round, not just in relation to the.

H

Hospital, we've talked about it before, but I think it's increasingly --. We have now.

H

Got some more material and I think it's increasingly urgent that we have a paper.

H

To the board in the next month or two which looks at that broad set of.

H

Propositions,, so we can feed in all our ideas..

H

The second thing is something we haven't talked about so much before.

H

Which I was talking about now, this business of community stakeholder.

H

Involvement and engagement, which is different from public and user.

H

Involvement and engagement- and that was the point I- was trying to make about.

H

These people not just being useful for inputs, but also for the improvement.

H

Journey afterwards and I think we haven't really begun to think about that.

H

And I think we should. My third point is just an offer; I feel I haven't at all done justice to Camilla's.

H

Question,, you must tell me David whether this would be useful,, but we.

H

Have, of course, been talking with the various inspectors about the way in.

H

Which Local Healthwatch could be involved in this going forward,?

H

If it would be helpful in my next report to the board, I can do a section on how we.

H

Think this looks for us and Local Healthwatch and what we're planning to.

H

Do in the next year, so the board can see that and comment on it.

A

≫≫ It makes sense to do that,. Can we agree that we'll do that and also bring a.

A

Paper back to the board on user involvement., Look, Paul and Andrea both want to say something.

M

≫≫ Mine was really just to reassure the board that, although this research was.

M

Commissioned on the back of what's been happening in wave, 1 and 2 in the.

M

Acute hospitals, it provides powerful learning and insight for what we're doing.

M

In developing for adult social care, as well, I, think the kind of constructs.

M

That Kieran gave us on standards of care, process and people have fed into.

M

The work that we have done, so on standards using those that exist in terms.

M

Of nice and social care institutes for excellence, but skills for care and.

M

National skills academy, as well, building, that into being because the consistency.

M

Issue is big for us, we're 25,000 locations and nearly a thousand staff,.

M

Building that into the planning tool, what the lines of inquiry look like,.

M

What evidence people should be looking at,, what the characteristics of good are,.

M

All of those kind of things. And, very much focusing on the people side of things, around co-producing, the.

M

Model between policy and the inspection teams,, but also focusing on very explicit.

M

Training and evaluation, and throughout our first wave we will be making sure.

M

That we're touching base with the inspectors, who are doing that on a weekly basis to make sure that that cycling of learning is happening.

M

Regularly and we will be evaluating what we're doing as well.

F

≫≫ So I think the question that really mattered is: what do we do differently as.

F

A result of what we've learned, part of that is what we'll do differently on the.

F

Inspection, but where we've got to is there really is a jigsaw that combines the.

F

Four elements of intelligent, monitoring,, on-going relationship management with.

F

Different providers and both those are year long, every day of the year.

F

Processes, plus, what happens during that week of intensive inspection and.

F

How much more we can build up in the six or 12 week period ahead of the inspection.

F

We really do need to get all of those things right and make sure they lock.

F

Together, if we're going to be confident about the way we regulate, so Kieran's report has been particularly about the process of.

F

Inspection but I don't think we can lose sight of those four,. That's one main bit.

F

Picking up two other bits very quickly,. We haven't talked that much about.

F

The expert by experience role relative to the clinical expert role,, but having been.

F

Part of an inspection yesterday in a forensic service in mental health in a.

F

Medium secure unit,, we simply would not have picked up some of the.

F

Concerns if it hadn't been for an expert by experience who could talk in a.

F

Language that was perhaps a little clearer than we are able to as inspectors.

F

In a way with people who are pretty marginalised,, so he got an enormous.

F

Amount of information. I don't want to under play. That. Just on the friends and family test, Camilla raised,. It is a powerful source of.

F

Information but it falls down when it's not standardised,, so the fact that we are.

F

Not standardising in the way we need to yet on the patient side or on the staff.

F

Side is a real, missed opportunity, and it's something we're in contact with other.

F

Albs to put right.

A

≫≫ David, you wanted to say something before I hand back to Kieran and Mike?.

C

≫≫ I think one of the key issues. -- Kieran has done us a great service with.

C

The report and Mike picks that up in the report that he published last week,.

C

Many of the issues as well. I just want to pick up on what Michael Mire was saying that came from the.

C

Dinner, though, about the importance of investing in our staff and supporting our.

C

Staff to do the job, we're asking them to do.

C

I think what we're moving from is a model of inspection which is based on.

C

Often single inspectors or one or two inspectors visiting large, complicated.

C

Organisations, to saying this isn't an individual pursuit,. This is a team pursuit.

C

And you need a blend of those skills; Kieran. You made reference earlier to.

C

You need people with a background and experience in regulation,.

C

Because there is a bottom line to some of this stuff and that bottom line will be.

C

Taking regulatory action,, if you don't know how to collect evidence and take a.

C

Statement and take the action, then this action that we should take that we'll fail.

C

To take quite frankly,, so there is a whole expertise. That's required around that,.

C

As well as; Louis to go right back to the beginning of the discussion,. Your point.

C

About clinical credibility and Paul was touching on that in relation to yesterday,.

C

And the forensic stuff.

C

So I think there is emphasis,. John might say something about this later. This.

C

Morning in relation to the review that they did of our readiness for the.

C

Transformation, about the importance of the academy and investing in staff,.

C

There is two dimensions to this,. First, there is the -- I'm, not sure this is the.

C

Right, phrase,, the conversion of the current inspectors as we move from a.

C

Generic model to a specialist model,: what are the skills we need to equip.

C

Them with,: how do we support them to do that? Job?.

C

I include managers of inspectors in this as well,, not just inspectors.,.

C

Then, as Michael Mire has reminded us, on three or four board meetings,. We are.

C

Actually set to bring in a significant increase in the number of people joining.

C

The organisation to give us the capacity to actually undertake the job.

C

We're asking them to undertake and they will come from services and will.

C

Need equipping with the capability to do the regulatory job, they might have.

C

The clinical expertise, but will need the capability,, so there is an extended form.

C

Of induction training required to support those people, do the job,.

C

So I think what Kieran's report does on the people. Aspect, is give emphasis to.

C

The importance of developing and growing our investment in staff and.

C

Making sure that staff feel supported. I think we've talked in the past of each inspector having about ten days away.

C

From inspecting during '14/15, so they can be supported in learning and.

C

Developing the new methodologies, I think some of the challenges and.

C

The learning which came out of Kieran's report need to be incorporated in those.

C

Curricula so they can be taken forward.

C

I think the other point to this, both Andrea and Mike, have spoken to this.

C

David, is that I think the six points that Kieran raised around people and.

C

Processes, about the issues around cost and consistency are not just about acute.

C

Healthcare, they're, as applicable to adult social care and primary medical.

C

Services, and while the architecture around improvement might be different.

C

For all of those,, this large small,, nevertheless, the legislation that gives us.

C

Our responsibility as we do this for the general purpose of encouraging.

C

Improvement in services, I think the legislation is pretty clear on this,.

C

And I think it picks up on the conversation about community groups.

C

And what the leverage is in relation to that and how we use it to take it forward,.

C

It doesn't mean we do the improvement,, but it does mean we encourage it.

C

So I think these issues need to inform the curricula that will be on offer from.

C

The academy that will help new people coming in or our current staff, in a sense.

C

Transfer from a current to new model,, it won't happen because we say so,.

C

It will happen because we support them to do that,. That's really why there is an.

C

Importance in investing in staff over this next period.

C

A

≫≫ Can I have Mike and Kieran,. Can you particularly address this standards and.

A

Intuition issue that a number of us have been raising.

I

≫≫ I hope our final report will help to give some greater certainty about that,.

I

We'll have some data about consistency of judgment, for example, that we don't.

I

Have at the moment- and it will be a longer report which I'm sure you'll love!.

I

I think the direction of travel is pretty clear.

I

The plea I'd make is that as you evolve, these systems, as you, for example, start.

I

To develop more explicit standards, that we embed some work to test the.

I

Reliability and consistency of those standards in the work of the teams going forward.

I

And, when CQC is challenged about how consistent your judgments are;.

I

Ofsted has had that challenged this week from the policy exchange report,.

I

You have the data to respond,, it's not necessarily a job for researchers like.

I

Me,, but that embedding of that kind of evaluation of the way it works in the.

I

Process is really important..

I

I'll stop at that.

G

≫≫ David I'll just try and give some headline responses to a number of.

G

Things that have been said.

G

This business of capacity to improve is hugely important, but will of course,.

G

Should, of course, be picked up within our well led domain, and we are assessing.

G

Whether -- I think it's a function both of leadership and culture, and because, if.

G

The leadership is there, they will recognise the importance of this and.

G

Give it due importance and have the ability to lead people through that.

G

Improvement,, but also where is the culture of a hospital?.

G

In relation to Michael, what you were saying about the Chair's dinner last.

G

Night, hugely encouraging that it was highly positive feedback,. But, having said.

G

That that's also what we've heard when we had chief executives and others.

G

Come back to us as part of our routine evaluation here within CQC, and what.

G

I've heard in other informal dinners,, so that's valuable.,.

G

David's already picked up on the old style, inspectors, I think it's really.

G

Important to remember that we hadn't, given them the conversion training at.

G

The time of wave, 1, and I think sometimes we were expecting them to.

G

Do tasks on the inspection for which perhaps they weren't suited,, particularly.

G

The interviewing of very senior people and that's where our team leaders and.

G

Our Chairs come in and sometimes our board level, doctors and nurses on these.

G

Panels, I think it's more peer to peer interviewing that we need to do and I.

G

Think we are now doing.

G

I'm slightly going to take issue with the word intuition, I, don't think it is about.

G

Intuition, I think it's about how we combine hard data from surveys, from.

G

Various other intelligent monitoring tool aspects with what we see and hear.

G

Which is evidence in itself and how we combine that.

G

We talked at the board before about how we combine five. Never events in the.

G

Past with what we see and hear of, has the WHO surgical check-list been fully implemented?.

G

And, that is always going to be a tension,, but what is important is that we.

G

Recognise it as a tension, that we have those debates in the, amongst a team of.

G

30 on the ground and that we're consistent about it across all the.

G

Inspections that we do. That's, one of the things that comes to the National Equality Assurance Group.

G

That I Chair, and say that's not how we would have called it in a previous.

G

Inspection and try to make sure we are consistent about that.

G

Then the point about adverse selection at public and patient listening events.

G

It can be the other way too, if people are frightened that their hospital will get.

G

Closed, they will turn out in their droves to support it.

G

But, what I want to assure people is that we listen to these events and use it as.

G

Probes,, it's not evidence on its own,, we say if all comments have come, that.

G

Vascular surgery or opthalmology is a problem area, that drives us to look.

G

At opthalmology or vascular surgery during the inspection,.

G

So we do take that advisedly if you like.

G

I just want to echo Paul's point about standardisation of the friends and family.

G

Test that would be enormously valuable.

G

Even within a Trust. It's the variation that we can already use,, because that.

G

Sometimes says those are the wards we can go and look at and we do use it as that.

G

Final comment, I think it's incredibly encouraging that the Chairs were all.

G

Saying yes to will this make a difference,, but we need to prove it.

A

≫≫ With the point that Paul was making earlier on, I'll leave it with you.

A

The other Paul and Mike, and the other chief inspectors on how we build in a.

A

System to evaluate the impact that we're having for the future.

A

Kieran can I. Thank you on behalf of the report for an excellent readable report.

A

That was very perceptive and incisive and we'll see you again when the.

A

Full report comes out again: I hope. Thank, you very much. You're, very welcome to stay...

A

We've got the three chief inspectors reports now, before coffee break,, we're.

A

Assuming that they have all been read, questions for any of the three chief inspectors?.

D

≫≫ This is really to just keep alive the discussion we started last time about.

D

Learning, disability, post, Winterbourne View,, so I just want to ask Andrea,.

D

I understand the responsibility is shared, but it falls most easily to Andrea about.

D

The progress post, Winterbourne View.

D

We had a meeting yesterday about this,, but something else happened. Yesterday,.

D

Nhs England published the latest figures on how much progress has been.

D

Made in response to the concordat on Winterbourne View,, so just to give you.

D

The figures from that, there were 2,577 people judged to be inappropriately.

D

Placed, people with learning, disability and complex needs in a Winterbourne.

D

View sense, people with complex needs need proper packages of care and need.

D

To be somewhere, else. Of that 2,577 --, so the commitment was to find a new placement by the.

D

1St of June 2014; so far of the 2,577, 260 have a date for a new placement.

D

And of them the date is before of that time of date in 172 cases,, so it is 10.

D

Percent who have a date at all and whatever the fraction is, about 7 percent.

D

Or so who meet that commitment.

D

Now, these are people who have complex needs not being met at the.

D

Moment by the current system,, so there is an urgent requirement to address this.

D

And we mustn't under-estimate the difficulty,, we mustn't just see it as if it is.

D

A matter of blame,, it is a difficult issue, because these are people who need.

D

Proper care for complex needs.

D

And, the system is trying to produce something which is often referred to as bespoke care.

D

Now, the families of people with learning disability talk of bespoke care, ironically.

D

Because the truth about bespoke care is that it is always the same thing.

D

They are looking for something a little more sophisticated,, so I raise this really.

D

To allow Andrea to simply comment and keep us alive on this issue.

A

≫≫ Thanks Louis,, it's very important to keep it alive.

M

≫≫ Thank, you Louis for the opportunity.

M

I did touch on this briefly in my report.

M

After our last meeting when we discussed the three lives, learning event,.

M

Followed that up with yourself and with Alan Rosenback, who sits in.

M

Paul's team, who was leading on the organisation of that.

M

The report that I referred to will be published in May,, but the discussion.

M

That we've had is to ensure that it's actually clear and explicit about what.

M

People are actually going to do.

M

Because I think what Louis has identified is that there has been a lot of.

M

Talk and commitments, but actually delivery is still wanting,, so we need to.

M

Make sure that we're very clear about what it is that we are already doing.

M

Within CQC,, what we plan and intend to do and where we can work to influence.

M

Other aspects of the system to make the improvements, but I think Louis made.

M

The point, frankly in terms of reading out the figures from NHS England, that three.

M

Years on from Winterbourne View being identified for the shocking care that was.

M

Happening there, and the attendant problems around that, a year on in.

M

Terms of today, being the anniversary of Connor Sparrowhawk, going into the.

M

Unit where he died 107 days later,, we have still got people having inappropriate.

M

Services,, so I think we need to be clear about what we can do, but also be clear.

M

Working with Bill Mumford, who is now the programme director for the.

M

Winterbourne View joint improvement programme and others, about what it is.

M

That we can do to make that difference.

A

B

≫≫ Two issues. They both came out of Andrea's report but are relevant to all three chief.

B

Inspectors,, the first one is around accreditation.

B

I wasn't quite sure where we were going to go with this,, because there is.

B

Accreditation and there's accreditation.

B

I guess there is the potential that if something is a service or an element of.

B

A service is accredited, then, actually we can take that as evidence and maybe.

B

Don't need to look at it in more detail,, but then again it might not fit our purpose,.

B

So I just wanted to know and understand where we might be going with.

B

Accreditation and the other issue is every now and then I get this anecdotal.

B

Example of where safeguarding hasn't, worked, and it seems a variable thing,.

B

To be honest, I'm not entirely sure how it should work.

B

But I think what our emphasis probably is,, is looking at the safeguarding.

B

Arrangements of providers that we inspect and I don't know how well we do.

B

That, because, as I keep hearing examples where things have seemed to.

B

Have gone wrong in those arrangements and I guess I just want to know and.

B

Make sure that, through our regulatory activities that we make sure or hold.

B

Providers to account, to make sure those arrangements work, by definition.

B

They relate to people in very vulnerable circumstances.

M

≫≫ Thank, you very much Kay and if I do a lead off response and then Stephen.

M

And Mike may want to add; on accreditation, absolutely the.

M

Question that you asked is the question that we addressed at the round table.

M

That we had with providers, with people using services and some of the.

M

Organisations that provide that kind of accreditation,.

M

Particularly in the adult social care, sector.

M

And, as I've said in my report, opinion, was split.

M

So there was some people who were absolutely mustard, keen that we.

M

Should be using it,, reducing our duplication and effort by taking.

M

Comfort from people being accredited,, there were concerns raised about the.

M

Potential burden on providers around yet another paper trail to be pursuing and.

M

Also, a concern that it might, in my sector, inappropriately benefit those.

M

Larger organisations with greater access to resources, compared to smaller.

M

Organisations which might be providing very personal, person-centred homely.

M

Care,, but not that which would be accredited in those ways,. So what we.

M

Have done to date is to say that the characterist -- and we will consult on.

M

This,, the characteristics of outstanding might actually demonstrate that services.

M

Have accessed and used accreditation, schemes,, so more of a sense of their.

M

Organisations that are progressing, are embracing improvement in terms of their.

M

Culture,, rather than necessarily saying this is a tick box that we want, everybody.

M

To have and that's the way that we prove that our service is good or outstanding,.

M

So it's one of those areas that our inspectors might want to look at,.

M

But we have to be careful about the nature of the accreditation scheme,.

M

Because there is also some fantastic really well based ones,, but there is also.

M

Other ones where people have got the badge and actually it's not,,.

M

Doesn't mean a great deal., On safeguarding,, absolutely right to say that what we need to be doing is.

M

Assessing that the arrangements that providers have in place around.

M

Safeguarding are appropriate,, it's absolutely clear and explicit in the.

M

Questions that we're asking,, certainly in the adult social care sector, and we have.

M

Also been doing some work, and that's the royal we,, it was actually Bill Hodson.

M

Our national professional advisor on social care, who has been leading on.

M

This, doing some work on defining the roles and responsibilities of the different.

M

Bits of the system in safeguarding, and that's something that we've seen at the.

M

Executive team and is going through the other organisations, including NHS.

M

Organisations as well so that we can be clear about what that picture. Is.

G

≫≫ Just on the accreditation point. We have been doing some work within the.

G

Hospitals directorate, looking at what the criteria should be for us accepting.

G

Accreditation, programmes; I won't get them all right,, but they include clearly.

G

Are the criteria used evidence based,? Has there been strong clinical.

G

Engagement, has there been patient involvement in developing the.

G

Accreditation programme,: what is the inspection programme itself? Like,.

G

What are the intervals between inspections, but importantly, for us,.

G

What's the fit with our five key questions?

G

And I think that's something that actually it would be useful if the three of us saw.

G

If we could have a united view on that,, but my view is that there are some.

G

Accreditation programmes, we will be able to accept really very quickly and.

G

That those will then cover areas of the hospital, or indeed mental health in.

G

Particular actually,, where we may not otherwise be able to do it and Paul.

G

Lelliott, one of the deputy chief inspectors has a great deal of.

G

Experience in accreditation and peer review and he is leading for me on that.

L

≫≫ Just a comment on child safeguarding because that sits under.

L

My new directorate and just to say that we're taking it very seriously,.

L

The new deputy who starts in April, Sue MacMillan has this under her wing.

L

We've reviewed the team which sits across primary and secondary care and.

L

Increased the number of people involved and also just recruited a head of,.

L

Across children safeguarding and health and justice.

L

Sue has already started to have meetings with other chief inspectors.

L

Including work with Ofsted and HMI prisons.

E

≫≫ Thanks. Good reports,. Thank you to all three.

E

Just two points that I think relate to all three,. The first one is about our role in.

E

Influencing the information authorities to get data we need, I was really struck by.

E

An interesting thing that Steve raised in his report about out of hours, services.

E

Being a data desert,, no doubt that also applies to community,, but the pressure.

E

That we are putting on the National Information Board to set the priorities for.

E

Data collection, I, think, is a question.

E

And, the second issue was Mike's lovely report and I noticed you have been out.

E

Giving messages which is great,, but it leads back to the previous conversation.

E

About supporting the system, I wondered whether or not we should be,.

E

If we're not already, thinking about what messages we can give to the sector,.

E

Particularly boards, with TDA and Monitor on ten big things, we've learned.

E

This year,, for example, on governance or well leadness, I, don't.

E

Know whether that's in the plan,, but it doesn't stray into us improving, but it.

E

Does stray into us providing easy support,? What are the ten things we.

E

Think boards should do as a result of our collective intelligence during the year.

E

Wouldn't cost much,, but it's just a suggestion on communications.

L

≫≫ Thank you, on data. Data is just essential.

L

It's, not just the information, -- I can't remember the new word,, a national.

L

Centre of information,, it's also bodies should provide, like CCGs, information.

L

We need in a timely manner and that's been a struggle. So far, still is a struggle.

L

I want to make two statements: really.

L

One is I support the care, dot, data concepts and I'm, really sad that it hasn't.

L

Moved forward, because I believe it will have really important implications for.

L

Improving healthcare research, but also the work we're doing, which is on behalf.

L

Of the public and I'm dismayed that it's been delayed and I understand why they.

L

Came to that decision. The second thing is just echo Paul's point earlier on about the friends and family test.

L

If you're going to bring in requirements on Trusts or surgeries,. You should.

L

Standardise it so you can compare and I don't understand why they are not doing.

L

That and it seems blindingly obvious to me on both,, but there you go.

G

≫≫ Yes in terms of data,, one of the key things that we need to press for is for.

G

Information to continue to to be collected at a hospital or location level, not at a.

G

Trust level,, because if we want to be able to say what is the maternity service.

G

At Newham or Whip's Cross or the Royal London like? Which is what the.

G

Public want to know,: we've got to have the data related to individual locations.

G

Not the whole of the Trust,, so we are making that case.

G

I think, surveys and making sure surveys are up to date. So we don't back off from.

G

Saying: okay, we'll do it once every three years? Actually, that's not useful to us,.

G

If we want to look at A&E or maternity or whatever,, we really need data. That's.

G

Within the past, year.

G

And the third element, following up on what Steve was saying on care dot, data,.

G

The key point I would make there is. Everybody is exhorting us to look at path.

G

Ways,, well, it's care dot data that will help us to look at pathways, every time.

G

Somebody says pathways, then let's say let's look at care dot, data.

G

The final point that also builds on something Paul said earlier is the.

G

Effectiveness domain requires national comparative audits. If we're really going.

G

To look at that seriously and as a country we invest very little at the moment in.

G

National comparative audits.

A

≫≫ Best practice...

G

≫≫ The ten big things, we've learned, I think what I would like to do is we went.

G

Cautiously because we were basing the first report just on 18 Trusts but I think.

G

By the time a year has gone past, we will have done 50 or more Trusts and I. Think.

G

At that point, we really will have more solid evidence on things we learned and.

G

I'm sure we should come out with our statements, I think we are in a very.

G

Privileged position of seeing what hospital care is like and, ultimately I think.

G

We will do the same in other sectors.

A

≫≫ Camilla,, then I think we'll break for coffee.

J

≫≫ Two, quick, points; I, really agree with you. Andrea about accreditation,.

J

I think you're right to be suspicious of it, personally I think there are a number of.

J

Schemes in social care, which really don't stack up,, there is a lot of people.

J

Making money out of it, I would really hope. One of the things our rating system.

J

Would do is actually shed some light on the validity of those schemes,. I would be.

J

Really worried if we were going to take most of them as read,. Our job is to make.

J

Our own judgment,, I, suspect ones in the NHS, are slightly better, but I think we.

J

Need to make our own judgment, if the other accreditation schemes support.

J

That, then, all well and good,, but I, think we need to be a bit wary about taking them on sight.

J

The other point; I know I made it before and it's never terribly popular.

J

On the data point,. Of course, we need the best possible data and need it in.

J

Realtime, I do wish. We could also just be cognisant,, particularly in social care,,.

J

About the burden we are placing on individual providers,, you mentioned that.

J

Andrea, when you talked about the worry of the smaller providers, have that the big ones have an advantage.

J

Later on we'll discuss the large amounts of money. We're going to put into reviews.

J

I do think we ought to consider whether we could just have some sort of look.

J

At what burden the CQC place, particularly on small social care,.

J

Providers,, what is the reality for the person, registered manager sitting in.

J

That office,, how many pieces of paper do they have to produce -- just in terms of.

J

Our overall mission, we are trying to be supportive as well as, we're trying to be.

J

Friend and foe, I think it would send a positive signal if CQC showed that it.

J

Was cognisant that we were putting a big burden.

M

≫≫ Thank you very much and one of the things that we're doing in the wave 1.

M

And 2 inspections is asking providers for an information return in advance.

M

Two reasons for that, one, because the standard data across our sector is.

M

Nowhere near as good as other sectors,, and also to actually try and help to be.

M

More efficient on the day that we turn up.

M

I have gone on inspections and you knock on the door, and the registered manager goes oh dear and I'm scurrying around putting together all the bits of.

M

Paper that the inspector is asking for.

M

So, what we're trying to do is bring some of that a bit further forward.

M

But as part of the evaluation,, we are asking the providers to tell us how long it.

M

Took them to complete that form,, how easy was it,? Was there anything we were.

M

Asking for they could have provided to us in a different way.

M

Was there anything they thought we shouldn't have been asking for, or other.

M

Information, they could have pointed us to that. Actually could have done that better.

M

So I think it's part of our commitment in the co-production is to be working with.

M

The providers to do that with them in the best possible way, and it will be a really.

M

Important part of our learning in wave, 1 and 2 to try and do that as efficiently.

M

And effectively as possible from both our points of view.

A

≫≫ Don't give up on that message,. We need to be reminded about that. All the time.

A

Good. Thanks very much., I think we'll break for coffee for ten minutes. Thank you.

A

≫≫ Let's kick off, welcome, Rebecca Lloyd Jones. Most of you know who is.

A

Our head of legal,, we thought it would be useful, so have her here when we have a.

A

Discussion about the appeals policy.

A

Paul you're going to kick it off.

F

≫≫ Thanks David, so as part of getting ready for the early April provider.

F

Handbooks publication for consultation,, we absolutely wanted to make sure we.

F

Understand our journey on appeals, and that that needs to cover the full gamut of.

F

Judgements that we make.

F

It's worth saying, as the first paragraph of the paper sets out, that the law has an.

F

Escalation to Tribunal process for certain parts of our judgements,.

F

Registrations and then conditions and cancellation of registration.

F

But for the areas that are around reports and warning notices and the ratings.

F

Themselves, that's covered by a separate part and isn't covered by Tribunals,.

F

So it's all the more important that we do have an appeals mechanism in place.

F

In looking through this, what we have been careful to do is to say there is.

F

Clearly, a long process that we discussed earlier in the board meeting that goes.

F

Right through the way in which inspection is conducted,, whether there is factual, accuracy, representations on the warning notices, all the way through.

F

To a rating, and what we don't want to create is a system where there is a great deal of duplications,. We want providers to have an opportunity to appeal against.

F

Different elements, but in the right way,, so, for example, at the moment we have.

F

Factual accuracy representations being made on reports and that we can absolutely continue.

F

But, we wouldn't want to get to the stage where then the separate appeal on the.

F

Rating,, which is what we're talking about in this paper,, would then go back to.

F

Initially, a second round of the same issue on factual accuracy, so we have.

F

Been clear on the way we want to delineate that.

F

The second point is to say that, with the regulations underpinning the Care Bill, if.

F

It becomes a Care Act,. Those regulations come in,, including the regulations on.

F

Ratings, most likely in October, so we're using the intervening period very much.

F

To learn as we go,, so what this paper is proposing is an approach post, October,.

F

However, we would want to learn and test it and review it. Pre-October.

F

The board has asked for two things, first is to approve the overall proposal for.

F

Appeals,, but specifically this element about independent reviewers, as part of.

F

The appeals process, and there what we're trying to be clear about is that in.

F

Law we can't and shouldn't outsource the decision-making process,. That's not.

F

Appropriate or right,, but we absolutely do want to have the right level of.

F

Independence modeled on some of the other regulators, so that if there is a.

F

Concern or appeal raised by a provider,, it is demonstrable that we have looked.

F

At that and independently had a view on whether there's merit in that appeal,.

F

Before it goes back to the chief inspectors as part of the CQC.

F

We think the way to do that is to have more than one independent reviewer,.

F

We're thinking about a system where we might have two independent reviewers.

F

And, for example, a deputy chief inspector looking at the appeal, so there is a.

F

Majority lay or independent.

F

So. That's one aspect: we're asking for the board's view: on.

F

The second is just a more general question for board advice on to how to.

F

Ensure the appeals process is sufficiently transparent and accessible.

A

≫≫ Thanks Paul. Rebecca did you want to comment at all or just listen for the time being?.

E

≫≫ No I'm happy listening, but if there are legal questions, I'm very happy to answer them.

O

≫≫ I was glad to read that Rebecca had been involved in writing. This report.

O

Because it is absolutely vital that we get the legalities of this right if it's going to.

O

Be sustainable in the future.

O

I have two questions,. The first question is whether, as I understand it. This.

O

System is an advisory appeals,. Somebody appeals to it, the appeal.

O

People,, the court or Tribunal or whatever it's called,, the panel,, comes to.

O

A judgment which then is advisory on the chief inspector.

O

I want to know whether we looked at the alternative, which is an internal process.

O

Where the CQC,, if you like,, reviews its decision and makes its own judgement.

O

Which is then the decision. Because I think there may be some confusion about what happens when an.

O

Appeal is made,. The appeal panel recommends a course of action,, but the.

O

Chief inspector decides on balance that he or she is not going to accept.

O

That, that may then cause consequential issues,, and my second question is.

O

Whether this process has been costed, and if so, whether the cost could be.

O

Approximatelily declared- and is it perhaps more importantly, in our budget?.

F

≫≫ So on the first,. It is exactly as you describe.

F

It is advisory. But, with a strong expectation that the chief inspectors will take on that advice.

F

Unless there was a clear reason not to do so., We did look at a number of different options,, including an internal process,.

F

We absolutely felt we needed that level of independence.

F

It won't stop us from also looking at any appeal on its merits: internally,. What I.

F

Suspect will happen in the normal discourse with the provider. Is there will.

F

Be concerns raised more informally before a formal appeal which gives us.

F

An opportunity to look at those.

F

On the second point, costing,. It is very difficult to cost this, because we don't.

F

Know the volume,, so we've tried to give some very initial estimates which I think.

F

Are absolutely at the top end on day, rates,, very much dependent on who the.

F

Independent reviewers are,, but this is one of the main reasons why we want to.

F

Test the process, pre-October, so we get an understanding in the budget --.

F

Understanding of the likely costs and we can make sure they're covered.

B

≫≫ Obviously: we need this process, but if we were getting lots of appeals that.

B

Were upheld, there would obviously be something wrong with what we're doing.

B

So almost by definition, we would really only expect to have if everything was.

B

Working properly, a few appeals,. What I was wondering,? Is it likely that there.

B

Could be speculative appeals?, Well I might as well appeal just in case!

B

And. That will be very expensive.

B

I just wondered: is there a way that we could offset that in some way?.

B

And one thing that occurred to me is whether people had to pay when they appealed?.

B

I know that can be controversial,, but it's this issue of appeal just in case, because.

B

There's nothing to lose.

A

≫≫ Eileen, did you want to comment on that?.

E

≫≫ Just to invite Rebecca to contribute, because we have to be very, very clear.

E

About the grounds on which you are able to make an appeal,, and they are.

E

Actually very limited,, importantly limited,. Whilst we can't say, or anticipate.

E

How many people will take up those numbers, and Rebecca will explain what.

E

Those grounds are, I think it's right to anticipate. In start up phase you'll have.

E

Many people thinking it is worth a go, and, as the process settles down, you'll.

E

Pull back to quite a small level of activity would be my anticipation,, which is why.

E

The model outlined in here has got a high degree of flexibility attached to it in.

E

Terms of the cost base,, so it's not about building a huge appeals secretariat.

E

Either,, but if we asked Rebecca to just outline what the grounds for appeal.

E

Could be, I think that would be helpful.

E

≫≫ Well you're right that we are clear that by the time you get to appeal your.

E

Rating, you will have had the chance to dispute and make representations about.

E

All the evidence,, so it's not a question of reviewing the evidence. Base,. It's a.

E

Question of reviewing how CQC applied its own process in terms of the.

E

Allocation of the rating in our proposed grid,. So it's a much more administrative.

E

Review,, not an evidence based review, and I think there will be a spike initially,.

E

Because people will want to test it out,, but that's the same as any time when a.

E

Whole tranche of new law is introduced,. There is always a period of it bedding.

E

Down,, but in the longer term, I think the numbers would diminish and I'm --.

E

I think we would have a filter mechanism where cases are looked at.

E

On the papers and if they aren't making out their appeal on the right grounds,.

E

We'd, send them back.

H

≫≫ Following on from that same point,, because I agree that there will be a.

H

Spike and it should decline,, but one of the ways in which I think it will decline;.

H

One of the influences on that rate of decline, actually I think it's about the.

H

Transparency around the process, so the question in here is about having the.

H

Appellant at the hearing and if I was thinking about this from the user.

H

Perspective I would always argue yes and say: logic requires that I say the.

H

Same in this case,, they should be able to hear the reasons which are being.

H

Given directly from those who are considering them in my view.

H

But I also think there is something about doing some learning reports from the.

H

Appeals that have been heard,, particularly in the early days, so that there is some kind of feedback to the regulated community about the basis for.

H

Successful appeals and the basis for unsuccessful appeals, so there is some.

H

Learning built into the system, which will help to support that decline.

H

I think we should also --, and we need to think about whether that's on a named.

H

Basis or general lessons basis,, but that's something we should want to commit. To.

H

Finally I think we should signal that over time, as we get a handle on how this.

H

Process is used,. We might wish to identify what we might describe as.

H

Vexatious appeals,, because I think it should be in our gift to refuse to hear an.

H

Appeal, if we consider it to be vexatious.

H

Now, what that would be going forward? I, don't know,. We won't know for some.

H

Time,, so we need a bit of case history to learn,, but we would want to do that in.

H

Due course, I think is an important thing to signal.

E

≫≫ The process looks good to me and pragmatic, I just wanted to ask whether.

E

Ofsted have not only the independent advisors but also give their advice.

E

Internally to the organisation, at the same level that we're suggesting,.

E

I.E. to a deputy inspector, and then that goes to an inspector?.

E

So, in other words, where does the independent advice going in Ofsted,.

E

Does it go to the board,, the chief executive or to the equivalent of a.

E

Deputy chief inspector? Was question number one.

E

And question number two, people can appeal, or at least -- against our.

E

Assessments, at the report stage as discussed here,, but also there is a bit.

E

Upstream, where they can also start to question, and it's not based on the.

E

Evidence but based on judgements on the evidence, which is where we are very.

E

Implicit still as we've just discussed,, so it's at the stage where we feedback to.

E

The Trust before we've actually got a written report, that actually it's the.

E

Judgement, that is the problem and it's to keep a handle on that,, because if we.

E

Don't get the appeals right then the balloon will squeeze and in fact people.

E

Might start appealing earlier.

E

If, you say this about our Trust. We will call in the lawyers kind of discussion.

E

So, it's making sure that bit is closed off as well or at least consistent with us.

F

≫≫ I have to get back to you at the meeting on exactly where in the Ofsted.

F

Chain it goes to, unless Paul knows?.

F

Absolutely I agree with you, because our appeals will be both on the process of.

F

Aggregating the ratings,, but also on the making of the individual rating.

F

Judgement, that balloon squeezing can happen.

E

≫≫ So, it's tracking, where --, it's also tracking, where we are being challenged.

E

Before the report, I think,, because obviously we've had some publicised.

E

Pieces in the HSJ about --, whether that's correct or not, about where we.

E

Have been challenged at that point.

C

≫≫ I think this is a really important point,. This came out in the dinner last night,.

C

To go back to this dinner,, where the majority of the Chairs there raised an.

C

Issue about the initial feedback and I think we've either not emphasised.

C

Or they've not heard this is initial, they've, seen it as definitive and raised.

C

The issue about what does the report go on to say, which is the space you're.

C

Referring to Jennifer.

C

Interestingly, the group that were there last night were of the view,.

C

Well, don't do the initial feedback.

C

And, at least one of them did have the opinion that actually they didn't need the.

C

Initial feedback, to leave this for weeks and not know what a view is, would be.

C

Just too much for people to bear, but I think it does play to the point that we.

C

Need to be really clear: this is initial feedback.

C

The reason. It's initial,, as Mike has said on a number of occasions,, is that the.

C

Unannounced component to our inspection is likely to take place after.

C

That initial feedback and therefore we are not completed in our assessment of.

C

The Trust and, notwithstanding the point about whether we ask for too much data.

C

Or not,, very often, if we asked for additional data, it's not there during the.

C

Course of the inspection, and therefore we actually want that data coming back.

C

To us to arrive at a firm view,, so we do need to reflect further on that point.

C

About what we do say, initial feedback and what we do say in the report.

C

I think that's what we were trying to get in this section on page 2 between what.

C

Can be challenged in the reports and what can be challenged in the warning.

C

Notice, as distinct from what's on page 3, which is what's challengeable about the.

C

Rating,, whereas in a sense, the rating challenge is a process challenge in.

C

Effect,, it's did. We follow due process, as distinct from did you agree with a.

C

Judgement,, it's not a re-hearing of the evidence that allows people to actually.

C

Pressure to make a different rating.

C

So I do think what this paper is trying to do, I think Jennifer, is be really clear.

C

About what is it that people can make representations about and what weight.

C

We should be giving to that and how can we ensure by the time we get to issuing.

C

A rating we followed our own processes and the way we got to that judgement is.

C

Entirely consistent,, there is not a logical gap in the way we've actually arrived at our view.

E

≫≫ Very important we're clear about that because at the moment there is a kind.

E

Of street view that we buckle if we are threatened with legal action before we've.

E

Produced our judgement.

E

I, don't think it's a widespread view, but it's certainly in the undercurrents.

C

≫≫ Is, it worth me just saying something about that: David?.

C

In wave 1 I heard two representations against warning notices.

C

I won't say where they were.

C

But in those representations, in considering those, one of the questions.

C

That we explored, and I did this through conversation with others, one of the.

C

Issues that we explored was if we were saying in place, X the failure not to use.

C

The WHO check-list warrants a warning notice,. What did we say in.

C

Places A, B,, C,, D,, E,, F,, G, I can't do it,. What's 18?.

C

But anyway, have we done the same in all of those?.

C

And the answer to that was no,. We hadn't.

C

So I, didn't uphold that representation.

C

I upheld the representation because I couldn't guarantee the consistency of the approach.

C

So, it's helpful that you've asked the question that we can now go on public.

C

Record that the issue there was not backing off, because somebody said we'll.

C

Threaten you,, it was that we couldn't guarantee consistency.

C

Both Mike and Kieran in their reports raised this issue about consistency,.

C

What we're determined to do is ensure that in wave 2, and certainly by full.

C

Rollout from April onwards that we are consistent in that.

C

Consistency has been a theme this morning,, so we will do that,.

C

And I'd personally like to scotch the rumour that we backed off because it.

C

Was a big beast that threatened us,? We actually said in the spirit of wave, 1 and 2.

C

Being about open learning that what we didn't have is confidence that we had.

C

Been consistent, enough, Kieran said that to us, Mike said it in our own.

C

Evaluation,, that's the issue. I think.

C

I hope there is not just a sub current about this,, but it can be a debate,.

C

We will be looking for consistency, the standardisation conversation we've just.

C

Had reaches to this and being clear about the evidence we collect and then.

C

The judgements we make and being consistent about that is a real issue,.

C

Those first 18 were hard,. We made a virtue of this, and I, don't think we should.

C

Be defensive about it. Whatsoever, waves, 1 and 2 were about learning and doing,.

C

Kay used that phrase earlier, about learning through doing,.

C

That's exactly what we have been doing.

N

≫≫ I very much take on board Kay's point and it raises the question which.

N

Was touched on last night about whether, in fact, there should be an appeals.

N

Process or whether, if the CQC,, if a provider disagrees so strongly with the.

N

Cqc rating and thinks they have grounds to go to a judicial review,, so be it.

N

But that the act of having an appeals process means people will start.

N

Appealing and they could appeal, as Kay pointed out, in large numbers, because.

N

We're not here just talking about acute hospitals, but of course, all providers that.

N

The CQC rates,, which it will be doing over the next 18 months.

N

So I think there is almost a question before one thinks about the paper,.

N

Should we have an appeals process,, or should our stance be, we're an evidence.

N

Based organisation,, which makes highly professional judgements, with great.

N

Integrity and if you think, there's legal grounds for disagreeing that's up to you,.

N

But we take this quite tough line about the quality of the judgements and the.

N

Ratings that we give and don't have this appeals process which, as I say,.

N

I think Kay correctly said, could open the flood gates.

N

So in a way, I'm challenging the basic assumption here, which is we need.

N

An appeals process.

N

Certainly last night there was as I, said, I, think, David and David, I think it's fair to.

N

Say there was pretty close to unanimity about don't get into the appeals, space,.

N

It will take you down a track which you really don't want to go down at all.

A

≫≫ That is absolutely the case.

A

This is a big point.

A

Camilla,, do you want to add to that?.

J

≫≫ I was really going to make the same point.

J

I started from exactly where Kay started, I thought it is going to become a badge.

J

Of honour for people to say, they've lodged an appeal, I totally agree with Michael.

J

I think what would be useful would be to some some cost benefit. Analysis, part of.

J

The argument in this paper is financial.

J

I think the rates being suggested for independent reviews are frankly.

J

Astonishing but it would be interesting, -- I know it's hard to know, but it would be.

J

Interesting to estimate the cost of judicial review as against this, I. Don't.

J

Have a feel for that, as to how big it could get, but essentially I agree with Michael.

O

≫≫ I think that Michael's argument is a very interesting and seductive one.

O

I'm not sure we should come to a definitive conclusion on this without.

O

Following Camilla's advice, which is really to weigh up some of the.

O

Pros and cons of doing it or not, and I think one of the things that distinguishes.

O

This paper, is it's a one solution paper and doesn't set out the thought process.

O

About the options that faced the authors,, that's not a criticism,.

O

Merely to reflect on where we are.

O

I would say on the experience of the CQC on the old inspection system.

O

Which, when it was first created as I, understand, it, I wasn't around at the.

O

Time, was, had all sorts of failures, but there wasn't an appeal system.

O

And, one of the things that it generated was a large number of complaints,.

O

It did have a complaint system.

O

And, what that complaint system,, what happened to it was it got clogged up with.

O

Complaints from providers about the way that the inspection had been carried out,.

O

It was being used as a surrogate appeals, mechanism.

O

So, just by not having a review or appeal system,, there are choices about those,.

O

Doesn't mean that the only option is judicial, review.

O

We might find that all sorts of other systems that exist are then hijacked to.

O

Let off steam in the system, and because of that is why I support Camilla's point.

O

About really looking at this and saying these are the options and the costs and.

O

Risks associated with them.

A

≫≫ It's interesting that last night, they made a big distinction between escalation, being able to raise it within CQC to a higher level. -- look. This needs.

A

More thought, Paul, I think and the three chief inspectors, can we take on board.

A

The comments and give it some thought over the next four weeks?.

F

≫≫ We will absolutely do that,. We do want to put something in the handbooks.

F

And bear in mind the handbooks are published on April, 9th and very much in.

F

The spirit of consulting and asking for views on this, we want more public.

F

Discourse,, so it would be helpful to know if we have the board's seal or not to put.

F

Anything in the handbook on appeals, I think there is also,. The question is.

F

Probably for Rebecca around the specifics on how costly JRs get, but my.

F

Understanding is, there is the question of whether we should or shouldn't from.

F

Some sense of expectation on the sector on moral obligation to have an appeals.

F

Process,, that's one thing,, but my understanding,. There is also a link between if it did go to JR, the process we had or hadn't followed in having an.

F

Appeal could have a bearing on the success of the judicial review,.

F

But Rebecca is the expert on that.

A

≫≫ Are, we not -- can't we pose the question in the consultation rather than.

A

Saying this is what we want to do. What do you think,? Why not pose the question?.

F

≫≫ We can, but we are also conscious that we are rating all wave 2 providers in.

F

The acute space, so between now and October there will be a whole series of.

F

Ratings out there, and that will be followed in due course by all the other.

F

Sectors so it's a live issue: whether we have a level of independence,.

F

Which is what we want to test. So I think we should pose the question openly,, but also be open, that we are.

F

Intending to test a process, pre-October.

J

≫≫ Sorry, what I am concerned about is, if we put it out there,. This is a decision.

J

For us to make not providers, about what is right and what we can defend.

J

My only worry is, if we put it out there, we create an expectation, and even this.

J

Discussion isn't making it entirely clear.

J

Obviously. None of us would argue that we shouldn't have a proper process for.

J

People to come back and question any fact: we've got wrong, any inaccuracy,.

J

There is a proper process for that.

J

What. We're discussing is whether you can appeal against. What's essentially a.

J

Judgement,, obviously, one of the most important things about the new model is.

J

That it is not just a tick box exercise,, it does contain judgement,, which is where.

J

It can become difficult to defend in certain situations,. My worry about.

J

Putting it out there before we've agreed, it is simply that if we then decide not to.

J

Do it, the headline becomes: CQC rejects appeals,, which would not be correct,.

J

Because it's not that we are not allowing people to appeal against various things,.

J

It's that we wouldn't be allowing appeals against other things,. You know what I.

J

Mean, I'm just concerned how that might be seen at a superficial level.

J

Outside the organisation.

A

≫≫ I, don't know Rebecca whether you could answer Paul's last point as to whether or not in order to obviate a judicial review going against this,.

A

We need to have an independent appeals, process?.

A

I, don't know the answer to that. Do. You know the answer to that?.

E

≫≫ I can have a go.

E

Our thinking is that the Care Bill doesn't set up an appeal mechanism and the bill.

E

Is compatible with the Human Rights Act, as it stands.

E

So, it would be possible to proceed and simply rely on judicial review as the legal.

E

Remedy,, that would be an option.

E

However,, the more we can demonstrate that we've dealt robustly.

E

And constructively with people's concerns about our application of our.

E

Internal processes, before it reaches that stage,, the less ground there is to litigate over.

E

So, we can give more thought to the cost, benefit analysis,, but I think what doesn't.

E

Get dealt with one way will get dealt with. Another way.

E

There might be some people that don't want to go ahead in JR, but there will be.

E

Plenty that do, so when they go and seek legal advice, if they are told actually.

E

This CQC process is a good one,. There would be much less, in terms of the.

E

Space for them to challenge us,, so that was the thinking.

G

≫≫ This is likely to come to a head, firstly in the hospitals area, because that's the.

G

Area where we are rating from now onwards.

G

And a particular issue in the hospitals area is that at the moment I am Chairing.

G

The national quality advisory group,, so I have seen all of these proposed ratings.

G

As they're coming through from hospitals,, so I may not be in an.

G

Independent position to deal with an appeal which in effect means it would.

G

Have to be another member of the executive if we were to do it, internally,.

G

If we were to treat it as we do, representations which we certainly could.

G

Do,, but that would probably mean it either ends up on one of the other chief.

G

Inspector's doors or David's or Paul's and I think this is something we need to.

G

Have a process for how we would handle representations about hospital.

G

Ratings,, we need to have that sooner rather than later.

G

We might want to put something around to board members to think about that,.

G

Even before the provider handbook comes out because I think we're in that.

G

Space almost from now.

E

≫≫ Just worth learning from the Audit Commission here,. They had a CPA,.

E

Their assessment and performance of local authorities, much more tense.

E

Space, chief executives losing their jobs and the politicians in local government.

E

Being judged by internal inspector and their capacity to be re-elected was.

E

Affected, Audit Commission managed it,. They had an independent appeals.

E

Process and as a result, very few things went to JR actually,, very few.

E

And from memory the Audit Commission won practically all of them because of the criteria that were very astutely. Crafted at the beginning,.

E

So there is precedent, here.

C

≫≫ In health and care, both CSCI and the Healthcare Commission rated,.

C

And the CSCI one then populated the Audit Commission and there were legal.

C

Challenges, JRs taken against the Audit Commission for accepting CSCI's.

C

Judgement and that fell because of the process that was there, which allowed that appeal.

C

The fact that it was documented and clearly documented meant that they.

C

Were consumed internally without going externally and the costs and time that.

C

Goes with that. We touched earlier about the undercurrents that all of that is transparent,. There is a process that people can see and observe, et cetera.

C

So I think, I take John's point that there is a one option: here.

C

So, we started with a premise that a good public sector body does have a.

C

Way of people making representations against its judgements and therefore.

C

What is that? And? The appeal is not against the judgement,, that's ours,, but against the.

C

Process bar which we got to the judgement.

C

And, leaving that space for people to come back to us, the process against the judgement is really what we're trying to get,. So we weren't retreating from the.

C

Space of this is our judgement,, but we were saying there needs to be an.

C

Opportunity for people to come back to us where they think we've got the.

C

Process wrong, so where we've got rules, the handbook, and we've not.

C

Followed those rules, and we've said it's XYZ array in terms or our judgement.

C

That there's an opportunity for people to say: oh,, yes, but you haven't followed.

C

Your rules,, the point earlier in the paper, is both accuracy on the report,. They can.

C

Come back on that and say actually you said there were 12 staff on duty,. Here's.

C

The rota and here's the pay bill there were 20 staff on duty,, so that becomes.

C

A matter of factual accuracy in the reports.

C

There is representations on the warning notices,. There were only 12 on duty,.

C

We want to take a warning notice in relation to this and if the warning notice.

C

Doesn't stack up because the evidence is wrong,, it doesn't compare going back.

C

To the earlier story in relation to wave 1,, then actually we have a process for.

C

Dealing with that.

C

So your point earlier Jennifer,. We need to make sure we have all those.

C

Opportunities covered between the report and the warning notice, so that.

C

Then left the judgement. On the basis. This is our judgement and we shouldn't retreat from that,. Then what.

C

People have got is an opportunity to say you haven't followed your process.

C

I think where we got to with Rebecca's help was that then means the gaming.

C

You are referring to that people will do it, because hey what is there to lose in.

C

Relation to this,, that was a feature for both CSCI and the Audit Commission in.

C

My view,, actually, what were you doing,? You were removing the opportunity by.

C

Just being really clear about what the appeal was for and what the rules are.

C

That people could follow, the risk. I. Think in my view, colleagues, is that if we don't.

C

Have some rules for that, we'll just create a great big playing field for people.

C

To play on and what we're trying to do is say actually we need to demonstrate.

C

We're fair,, it was one of the things that came out of the conversation with.

C

Kieran,- and this is a way of getting some element of fairness in the process.

C

Without retreating from what our formal -- and when the Care Act has.

C

Royal ascent, our statutory responsibility is to rate services,. So that's what we.

C

Were trying to do if that helps, as Jennifer's reference back to the Audit.

C

Commission and our predecessor bodies that rated, then I think it's very,.

C

Very helpful history to actually inform the decisions that we actually need to make.

C

I think Paul's point about. We do need to settle this, for the handbooks is not to.

C

Force people into a decision that they feel uncomfortable with, but I think.

C

Mike's is even more expedient,, we are going to rate all of wave 2 and we need.

C

To send some signal,, although that's under the old legislation, and not new legislation, of how we're going to deal with this.

C

So, the timing of this is a pressing issue that we need to be clear for the.

C

Handbooks,, but actually having some principles by which we can deal with.

C

Wave 2 coming forward is what we're also attempting to do. Here.

C

So we can take it away and do more work,, but I would ask that we can send.

C

A signal in the handbooks of what we are trying to do.

A

≫≫ I'll just ask Paul Corrigan,: do you have a view on this?.

A

You have to press your button. If you have a view, I'm sure you do.

K

≫≫ I think the predecessor bodies and the Audit Commission managed a very,.

K

Very contested terrain really well, and in a way which, as Jennifer was saying,.

K

There was politics involved, as well as people's careers, and people who were.

K

Involved in local government accepted it., So I think if they managed that political terrain well, there must be lessons for us.

K

From there,, if they had an appeals procedure, I think it would be dangerous, not to..

D

≫≫ I'm, beginning to think this title I was given friend or foe, was the most astute.

D

Thing I have come, across, I think we do have to think how this would look to.

D

People out there,, if we have no -- I, rather enjoyed Michael's argument. I.

D

Must say, but I'm not sure I agree with it in the end, because I just cannot see.

D

How we can look like we are friend, not foe, to concerned clinicians and.

D

Concerned patients, if we are not prepared to consider where we get it.

D

Wrong or we get our process --, we don't do what we'll say we'll do.

D

So, on those two grounds that we made a mistake,, we didn't get the detail. Right,.

D

We misjudged what was going on,. We have to have some way of letting people.

D

Come back to us on that, or, that we didn't do what we said. We would do,.

D

We have to have some way for people to come back and tell us that.

D

So on those two principles, which I understand as the basis of what's being.

D

Proposed, I would broadly support it and broadly support going ahead with.

D

Whatever we need to say publicly,, even if it's couched in consultative terms,,.

D

I think we can look forward to say these are the principles we're trying to get right, and this is where it takes us to at the moment and of course, we're.

D

Prepared to consider people's views about that.

A

≫≫ I think that's where I am, I hadn't thought about this enough until Michael.

A

And others have raised the issue about whether there should be an appeal.

A

I think I'm, where Louis is.

A

Is that the general consensus we should go on that basis, that there is a narrow.

A

Appeal around process, to an independent party or do people feel very.

A

Strongly that we shouldn't do that?.

B

≫≫ I think we should go ahead and make it clear that it's a very narrow.

B

Basis personally,, having listened to everyone.

A

≫≫ And raise the issue about whether there should be an appeal process in the consultation as well?.

M

≫≫ David, if I may?

M

Our strategy said we wanted to build better relationships with those we.

M

Regulate- and that is one of the overarching strategic priorities- we've got,.

M

Being absolutely clear about how we're going to do it will help,, but I think that.

M

There is something about us being --, I, think sufficiently confident to come back.

M

To one of the points that Camilla was making, to say, we should open ourselves up to that appeal, process, on the basis that actually it will help us to.

M

Learn,, if necessary, it will help us to demonstrate that we have actually.

M

Followed our process,, if that's the appropriate outcome,, but it also means.

M

That, as a public body, we are open to that scrutiny in a way that I think actually.

M

Helps build confidence and credibility in what we do.

M

So I'm as guilty as anybody in thinking we should get on and do it and it's about.

M

How we do it rather than taking you through the process of getting us there.

M

But again other public bodies and my experience back at NICE in terms of.

M

Having an appeal process around that, was also very instructive to me in terms.

M

Of my influence on this.

E

≫≫ Just a quick point,, there's a thread that runs through a lot of the papers this morning, which is about our overall communication messages and strategy,.

E

And I wonder if at some point we might just have some time on what our overall.

E

Message is for us, as an organisation going forward on a range of issues.

O

≫≫ Very quickly.

O

I support a process of review, of it being challenged within a system which is.

O

Within -- involves us, rather than going externally to the court,. What I am.

O

Uncertain about is whether that should be an internal review or external review.

O

Or an appeal,, because this isn't an appeal: this is just a review of the case,.

O

That's my uncertainty about it,, but if we need to start the process of explaining.

O

That A,, we wish to be challenged ourselves rather than saying you're on.

O

Your own, go off to the court and that we are trying a system,.

O

Then I'm happy to go along with what's proposed.

O

>> I'm happy to go ahead on the basis --. The presumption is is that we carry on.

A

On this basis,, but it is a rebuttable presumption.

A

We can come back to this. Can't we before October? In the light of what we.

A

Hear from people or our own views?.

F

≫≫ We absolutely will,, not least when we come back with a response from the.

F

Consultations around the provider handbooks.

A

≫≫ Okay last word from Michael.

N

≫≫ I don't want to have the last word, but the section in the handbook for acute.

N

Care is very specific about the appeals process,. It says within ten days,.

N

Within 14 days and so on.

N

It's so detailed that it almost feels like isn't a consultation,. We are going to have.

N

An appeals process, and we know what it's going to be down to the last day in.

N

Which you can make the appeal. So I think the consultation needs to make the appeals less specific and.

N

More general, but I think it should also stress, which it does,, but because there.

N

Is the appeals section, that there are these other very important steps in.

N

Challenging the CQC,, the one that David mentioned,, the sheer accuracy of the.

N

Information we've used versus the information, the hospital or Trust may.

N

Have, and then the ability to challenge a warning, notice.

N

So there's lots of challenge in the system and I think probably in the.

N

Consultation paper, -- I, don't want to try and sway this to my thinking, but I think.

N

--, if it was possible that you could argue this is two bars,. The consultation.

N

Question could be -- I'm, not trying to word it exactly now,, but as the CQC is.

N

Completely open to challenge on factual evidence and on warning notices,.

N

Should there be a further appeals process, -- again I'm biased, I'm, leading.

N

The witness here.

F

≫≫ We're happy to be led: I, think., Paul?.

F

≫≫ Let's look at exactly what the consultation question. Is, we'll circulate. That.

F

On the details that are in the very, very draft version of the acute handbook that.

F

You've, seen, I think those numbers are very much to provoke thought, rather than any sense of them being the right numbers and if it's inappropriate from.

F

The purposes of this conversation, we can absolutely take them out, but they.

F

Certainly, shouldn't be seen as any signal to the system.

A

≫≫ That's very helpful.

A

Paul,. Yours is the next item as well, thematic topics.

A

Rebecca, thank you very much,. You can stay if you wish.

F

≫≫ So last month we brought a proposal for the process around selecting.

F

Thematics for 14/15, which the board endorsed with comments.

F

And, at the same time, endorsed the approach of having up to four large.

F

Thematic reviews and up to 12, smaller thematics,, but very much in the spirit.

F

That they had to really add value, and we talked about two and a half to 3 percent.

F

Operational resource implication of that, up, to, and again I think the central.

F

Theme of the work we've done since then is this has to be manageable within.

F

The workload of our inspectors,, we can't trade, so we don't have a comprehensive.

F

Inspection process.

F

So. This paper then sets out the suggested list of thematic reviews both.

F

Smaller and larger,, but very much for discussion with the board.

F

It's worth drawing out three or four points.

F

Firstly in a previous board meeting five thematics have already been endorsed.

F

For 14/15 and those are brought out on the first page,, some of those are pretty.

F

Big pieces of work,, for example, on end of life care and on dementia, care.

F

The second part is to say if the board's view is that we should have more rather.

F

Than fewer thematics from the list or from additional ones that you think we.

F

Should consider,, then it may be that we need to come back and say looking at.

F

The resource implications in the round,, alongside our on-going inspection.

F

Activity,, there is only a certain number that we can do of these in 14/15 in.

F

Which case we propose that we have a pipeline process and we put the ones.

F

That are lower on the priority list,, but also still important in the pipeline,.

F

Keep a careful eye on whether the world moves on or not, but always come back.

F

To those as we're planning our 15/16 thematic programme.

F

The page 2 of the paper you have just sets out the selection process and if I.

F

Just finish with two points, one: to give information, there were 31 thematics that.

F

Were considered in the long list and don't make it into this paper, just to give.

F

You a sense of the large number of ideas that were brought forward,. That's.

F

Following a reasonable consultation, informal engagement, exercise,.

F

Including with members of the board. And, finally, as it sets out in the paper,, there are two thematics where there is.

F

A public commitment to do them already,, so unless the board feels very strongly I.

F

Think we'd expect to do those.

A

≫≫ Thank, you very much Paul, any comments for Paul?.

B

≫≫ Just to seek reassurance or assurance that we have the capacity.

B

And capability to deliver all of these,, because I know David Behan said.

B

We're running hot, so just to be clear: we can deliver them and deliver them. Well.

B

The other thing was we often get asked to give examples of good practice,. Can.

B

You point us to somewhere that's doing complaints well or is there somewhere.

B

That involves patients, well?

B

And I just wondered if the good practice bit was sufficiently prominent in some of.

B

These reviews,, because sometimes we give examples and maybe that's okay.,.

B

But I just feel that, given that we encourage improvement and given we're.

B

Looking more indepth,, we can even have; consider a review that is actually.

B

Looking at good practice of a particular issue,, the one thing that springs to mind.

B

To me is, for example, around how well providers engage and support staff,.

B

What organisations do that well, and how do they do it? Well?.

B

Because that, I believe there is evidence to suggest that where staff are engaged.

B

And supported it has a really big impact on the quality of care,, so that actually.

B

Could be quite a significant way that we could influence good quality, care.

D

≫≫ I feel a bit guilty about this, because first of all, I have a feeling. I must have.

D

Missed a phase in this consultation, I, don't remember seeing the 31 topics,.

D

Although did I see a list of topics which I commented on, but I'm saying I may.

D

Have missed that,, not in a sarcastic way, I'm saying I genuinely may have missed.

D

It, but that's important because I don't recognise where quite a few of these.

D

Topics have come from and to me this list,. This is why I feel guilty, I'm, afraid.

D

What I'm going to say will sound rather critical and it may sound like criticism that we've gone over previously. But. It does highlight for me where we're not absolutely sure yet what the.

D

Thematic reviews are quite for and what people are expected to do with them,.

D

So I do feel the list is slightly still reflecting that,. It is a bit of a mixed bag.

D

Of things that sound so huge, they are almost the entire work of CQC,.

D

How safe is care?

D

That sounds like more than a thematic review to me and then some specific.

D

Points which I suppose sound more doable and manageable and worth the expenditure.

D

So I'm a little unsure how we got to this point, I'm a bit doubtful of some of.

D

The examples and I'm still unclear what we will be able to do when we have the answer to the review.

D

Just, to give a couple of examples: there, the one on depression, the question it.

D

Will answer is how well is depression recognised in different parts of the.

D

Community sector,, the answer is not very well recognised.

D

So I can save us an enormous amount of money by doing that review. Myself.

D

But there is a question,. There could be a question about how well the much.

D

Lauded psychological therapy services, which, when I, was working with the.

D

The Department of Health I was partly instrumental in setting up, but how well.

D

They've really done, what we thought they were going to do.

D

That's, a much more specific question about a nature of care. Delivery,.

D

It's a more modern question,, because it's about a recent development,.

D

It crosses the sectors, because they were designed to cross primary and.

D

Secondary care boundaries, and it's also reflected a lot of criticism in.

D

The field of those services, so answering a question which people are raising a lot.

D

Of but there is not a huge amount of evidence,, so there could be one on.

D

Depression but a much more focused one.

D

I, rather like the idea of complaints or something like complaints being a topic.

D

Because, but I would give it a slightly different emphasis and it comes back to.

D

The question I asked you before,, which was whether we were in a position ever.

D

To develop a science of complaints,, otherwise we're in danger of thinking.

D

Complaints are important, but not knowing what way to turn them into.

D

Usable information and doing a bit of practical fieldwork, which might include.

D

Looking at good practice in individual settings on how complaints can.

D

Be turned into, because they are often free ranging,. They come from some.

D

People not others, how they are turned into a more balanced consideration of a.

D

Service, how they become more objective and scientific.

D

So. There is a possible point,, specific topic about complaints, but it might not.

D

Be the one we've set out at the moment.

D

We talked about medicine management in care, homes,, that's not on the list,. That seems very important to me. Maybe it's somewhere else,, but it does cross two sectors.

D

There's one on looking at the 7 steps in the NPSA that feels a bit old fashioned.

D

That's an old suggestion to the service, looking back over how well that was.

D

Implemented some time ago may not be the top priority.

D

Can I apologise for sounding so critical,, but I just felt. Where is this taking us.

A

≫≫ That's helpful.

A

Shall. We come back to you Paul at the end?.

E

≫≫ I thought the objectives for the thematic activity on page 2 were good.

E

Ones and I remember discussing those and the two further selection criteria.

E

Were also good.

E

I'm agnostic about the actual list, I think it looks,. Some of it looks sensible and.

E

The questions could be rephrased, such as how could depression be better.

E

Recognised,, that could be a more specific question,. The only thing I would.

E

Say from experience is less is more here.

E

There is only a certain number that the service can digest, err on the side of.

E

Parsimony and I think we can debate the precise topics, but it's clear to me.

E

Anyway, thank you.

H

≫≫ When I looked at this paper. I read it and moved on thinking how the hell.

H

Does a board make this decision, and that's because I recognised the criteria,.

H

The filters you'd already put it through, they've, worked because we've.

H

Got some things that would be very interesting,, but they didn't tell me which.

H

Ones to do and we can all choose our favourites,, but that's not the way to do. It.

H

So then I got to the business plan paper and we've got our nine areas of focus in.

H

The business priorities, business plan for this year and I think it's really important.

H

That we keep ourselves focused on those in the next year,. We have so much.

H

On our plate that it seems to me anything we do in thematic space needs.

H

To play strongly into the work in the business plan, and while all of these.

H

Could do in some way,? It seems to me anyway that one or two of them did.

H

Much more clearly.

H

I could identify those, I, picked complaints and whistleblowing,.

H

It appears in priority one in the business plan, there loud and clear, and another.

H

One on integration, which is a bigger project, which isn't as well defined and.

H

Probably needs a lot more work because it fits into this category of the world and.

H

Everything, but again, that's very much there in priority four and we don't really.

H

Know yet how to do this in inspection, space.,.

H

So my question back to the senior team is,, these all look fine,. The process looks.

H

Good, but which of these will help us to deliver the business plan in this year or.

H

Will help most to deliver the business plan in this year?.

H

Because, that seems to me the basis on which we should make the decision.

A

≫≫ Paul and Camilla.

K

≫≫ Something I'd not thought about until Kay said about best practice and it links.

K

In with things that have been running through a lot of what we said today,.

K

Which is how do institutions improve themselves?.

K

And, there's lots and lots of examples of good practice around that no-one takes.

K

Any notice of at all.

K

And, it seems to be not very useful to add to that list.

K

But on the other hand,, we would have a lot of information about the conditions.

K

Under which institutions do institute practice from outside,, because that's.

K

What we've been picking up through inspections, some will be saying: we got.

K

This idea from X.

K

So it would be interesting to know not just where good practice is, but what are.

K

The conditions under which that good practice can be implemented,.

K

So on page 2, when it says, encourages improvement,, it seems to me part of.

K

What we need to start doing is find the conditions under which organisations can improve.

K

And, we can do this in any of these topics, and so it seems to me it's not just.

K

What is a piece of good practice,, but how does it,? Why do some organisations.

K

Do this and some not?

K

Because, then that becomes part of well led.

J

≫≫ The criteria are very good and we've agreed them before,, I'm, not sure all of.

J

These meet our criteria,, particularly on the question of why CQC,, without going.

J

Through the list,, I would like to see a much more extensive explanation of.

J

Why, in most of these cases, there are a number of other organisations that.

J

Have already done, work in this field, are doing work,. It's not costing us money for.

J

Them to do it,, the question is: are we an aggregator of other people's data or are.

J

We adding something unique, on a number of these. It's not clear to me.

J

Whether we are or not, and I just wonder, -- I think Louis and Jennifer both made.

J

The point, we need to really tightly define the question, when you write --.

J

Absolutely clear in the way you write the question, as to what the impact is.

J

When I see something that says how well I'm, always slightly losing the will to live!.

J

On the integration point, there is so much work going on already on that.

J

I just would really like to be convinced as to how we are going to add,. It may be.

J

That we need to be more aware of what's out there, but I'm, not quite sure how we're going to add to it.

J

I wondered -- back to what Louis was saying, I, wonder whether each one of.

J

These almost needs to have a board sponsor, or the chief executive, sponsor.

J

I sort of feel that I'd like to see one of us just making the case, when we got down.

J

To the short list and saying why are we going to do this and nobody else, I, feel I.

J

Haven't had that experience, I think if you've people around the table with.

J

Incredible expertise, is this the way to leverage that, I, don't know,, otherwise, it.

J

Seems a little bit divorced from -- and there are individuals around the table.

J

Who have particular passions which might be of interest, and I? Don't know if that's the way through this,, but I just think. We need to be a bit more rigorous about whether it's meeting what we set out to do.

A

≫≫ Paul, would you like to respond to the various comments made?.

F

≫≫ If I go through them in order I'll try and do it at a pace, but not in a glib way.

F

Kay, you started your two questions,. The first was about given how hot we're.

F

Running we have the capacity to do this, I think it's --. On your first question, Kay I.

F

Think it's too difficult to say definitively that we have the right capacity,.

F

Not least because in most of our sectors, we're going to be learning in the first half.

F

Of 2014/15, just what it really takes to inspect, that's the process of wave 1.

F

And 2, and that's why we want to have this buffer of a pipeline, to be able to.

F

Come back to the board and say for the ones you prioritised: this is what we can achieve.

F

Realistically, we are not going to be doing much actual work on the ground.

F

On these new ones, in the first half of 14/15,, we'll be doing lots of work on the.

F

Five, that are in the paper and already agreed,, because they will be much more.

F

In the scoping and design phase,, so we can run those two processes in parallel.

F

Are we setting out the good practice? I, think it's a great challenge,, so I think implicitly, -- I had the view. Yes, we would always do it,, but the way to do.

F

That is to say, every single thematic needs to systematically, in a structured.

F

Way, say both to your point,: what is the good practice we're seeing, and to.

F

Paul's point,: what are the conditions in which it's being implemented,.

F

And why would we believe other people can learn from it?.

F

Louis, on your points,, you absolutely didn't miss a step in the process,.

F

The process we ran was to ask for everybody's views, but we didn't include.

F

You in the process to be honest,, then feeding back all 31, I can absolutely.

F

Share them, as well as the number that have been included for discussion, here,.

F

But there was no step in the process that you missed.

F

I think you're right, some are very big and some more contained and depression is.

F

A good example of it.

F

A lot of people -- for any individual and there are people with a great deal of.

F

Expertise and could probably give you the answer,, I, think being able to give.

F

You the answer with a specificity on region by region or sub-regionally, and.

F

Also, the conditions in which it's successful or not and which aspects are.

F

Is probably where we want to focus more on the thematic, but the key point.

F

Is some of these really aren't deliberately tightly scoped and we have 50,? There is.

F

A limit to how much detailed scoping we can do on all of these, given all the other.

F

Work we're doing, we'd much more wanted to come with. This is the areas,.

F

We're under a statutory duty to come back to the board with the scope of any.

F

Section 48 report, when all these thematics will be done under Section 48 of the Act.

F

So we would come back to the board in one form or another, to test the exact.

F

Scope, and key in that will be the exact question, but also the design and.

F

Methodology of the approach.

F

On, the science of complaints,, there is certainly one of the thematics looks at.

F

Complaints outside of acute, we're already doing so much work in the acute.

F

Sector, particularly on this.

F

And, on the 7 steps,, the reason we included it was because the view.

F

From our safety experts within CQC was that that was,, it was ten years ago,.

F

But it was an extremely important piece of guidance,, which is relevant today, as.

F

Much as it was ten years ago, and the concern is that why basic things like.

F

Root cause analysis are not being effectively carried out in the system and.

F

To understand Paul's point,, why is it that this good practice isn't actually always landing?.

F

So, it wasn't just to say, did something happen or not,, it was to say if we think.

F

This was right all along. Why hasn't it been systematically done?.

F

Jennifer,, less is more is also good for all of us on the exec team. We'd rather be.

F

Able to do the things we do well,, but in terms of what we put in the pipeline if.

F

We can do it versus what we do,. We want to apply that principle.

F

Paul, I think on your comment about the conditions of best practice,. That's picked.

F

Up in this way in which we do a structured thematic that looks at good practice and how.

F

Camilla on your why,, whether the why CQC has been, is the right organisation.

F

To do the piece of work, you're right when I look at the scoring criteria, there.

F

Are some that score more highly on that and less,? That's absolutely right,.

F

I guess the question is there had to be above a certain bar, but it's perfectly,.

F

If somebody else could do it equally as well as us,, then we should kick it out.

F

I personally, like the idea of board sponsorship of individual thematics,, it's better placed once we've selected the ones to do and that can sit alongside.

F

The fact we want to have a joint ownership within the CQC, that's.

F

Operational,, as well as policy people both owning these pieces of work,.

F

That would only be strengthened by having a board member who was.

F

Responsible,, probably more about that side of it than individual board members.

F

Saying this is the one I want us to do because of all the challenges that brings.

A

≫≫ Thanks Paul, I, don't feel we're really comfortable in this area,. To be honest,.

A

With you,, it doesn't feel hard enough.

A

I, quite like Camilla's idea of someone's got to have a real passion for what we're.

A

Doing and why we're doing it, it's a bit like going to the sweet shop, we're.

A

Picking out lots of different packets of sweets at the moment, and we should.

A

Be focussing on the gobstoppers,. We should focussing on something that we really want,. Do you feel the same or...

C

≫≫ If I could make a suggestion, I. Think the point about connecting this to the.

C

Business plan is very powerful.

C

I think the issue about what's worrying people out in services about whether.

C

This stuff is working and then this point about what works and what doesn't and what do we know.

C

I wonder on the topics that are there: whether there is a way of becoming.

C

More comfortable of learning by doing model in which case, I think the idea of.

C

A board sponsor of somebody who will actually give some support,.

C

Encouragement and challenge and passion for it: I think, I'm, with Paul,.

C

I think is a really good idea in relation to this.

C

If any of that works David, then what I think the report is indicting the board to.

C

Do is consider a two and four,. You don't have to do two and four coming back to.

C

The running hot and resources issue.

C

I can't believe we're not going to get through this year without somebody having another idea about something we might have a careful look at, so building headroom in here...

A

≫≫ The organisations that do adapt from the outside...

D

C

≫≫ So, where I was going to go with that (inaudible).

C

I think Jennifer wants to come. In.

E

≫≫ It's a great point about context,: we've just done a review of this and actually.

E

The results are pretty boring in a sense because the same things come up every.

E

Time, leadership, culture, that kind of thing.

E

It's, often very difficult to distinguish between different services and issues,.

E

It's the same set of internal context, ingredients.

E

We just published something, I'll send it to you.

A

≫≫ Kay raised complaints for example,, that's specific,. We can look at best.

A

Practice,, the best hospitals that deal with complaints how they deal with them.

A

≫≫ So, where I'd go with this is I. Think Louis is reframing the depression. One.

C

About what do we know about psychological therapies,? Why is it given.

C

Traction in some places and not others,, there seems to be a fundamental issue.

C

About the impact on people in communities, whether you have access.

C

To that or not, and that might be one to look, at.

C

I think the issue about trying to anticipate the future,. It seems to me that.

C

The approach to the development of acute healthcare is predicated on the.

C

Back of building up community based services across health, primary care and.

C

Community healthcare and I think the proposition about vulnerable people.

C

Might speak to that and we could say something: intelligent, -- lots of.

C

People saying what it should be, but I'm not sure anybody is actually saying this.

C

Is the reality of being old and living in Blackburn.

C

So I've just covered in my comments. Number two and number four.

C

I think, just picking up on what other colleagues have said in relation to the.

C

Shorter ones...

C

C

≫≫ I'm trying to give a way to have a conversation that allows us to either.

C

Walk out of here saying we're not doing any or walking out of here saying this is.

C

What we're doing, I'm trying to get us to that or if you don't want to us, do any I.

C

Think that would be a shame personally,, because my view is if we want our state.

C

Of care report to be authoritative and say something, then actually, this is the.

C

Evidence that we need to collect to get to that.

C

I think the contribution colleagues have made this morning in terms of what they.

C

Would want it to be on? Why do some things, work and others don't,.

C

What is the lived reality of some people using new services,? How prepared are.

C

We for a major investment in community healthcare services,, which is actually.

C

Predicated on the back of a whole strategy,, it strikes me, for acute.

C

Healthcare, seem to me to be important things that we might want to give.

C

Comment on,, but if we do want to comment on that,, we need to collect the.

C

Evidence, otherwise we end up being a pollemic organisation which is making.

C

Commentary on things based on I'm, not sure what.,.

C

If we're going to get evidence to comment on then our inspections are.

C

Part of that evidence,, but evidence from inspections by themselves will not.

C

Answer some of the questions that have been provoked by this,.

C

So I think the list is an attempt, you're right, David I think we need to go to a.

C

Greater sense of competence and maturity about selecting these,.

C

But at the minute this is where we are, I think from what colleagues are saying: I.

C

Think they probably are two longer pieces of work. I would offer Camilla,.

C

It's a suggestion, I'm not trying to lead you at all, I'm, certainly not in Michael's.

C

Position of leading the witness on this, but I think Louis' challenge on the.

C

Depression, one was great,, I have skin in this game as well.

C

Because I was a civil servant that led the roll out of psychological therapy, so.

C

We've both got skin in the game, but knowing has it made a difference? Might.

C

Not be a bad question to answer.

C

If, it has made a difference, where and why has it and if it hasn't where and why.

C

Has it not made a difference.

C

The points about consistency with the business plan? Probably would take us.

C

Into complaints and whistleblowing, notwithstanding the work that Michael is leading.

C

I think the issue about safety could actually be a direct lift,.

C

And, notwithstanding your point, that maybe we know about this,, if safety is the feature of the way that healthcare and care system needs to.

C

Operate,, what do those 7 steps? Mean?.

C

So, it might not be just about safety, but actually Paul's, question about. Why do.

C

Some things, work and others not work,. So what I'm offering is a way of trying.

C

To go through that list and come up with some work here that might inform the.

A

State of care, report. >> We're, not against doing thematic reviews and we've set out the criteria.

A

Under which we will assess thematic, reviews, I think it's probably a mistake to bring lots of them. Here, I think we want the two or three that you've worked up in.

A

Some detail,, if it was depression for example,, so we can then tailor it more,.

A

I think that's what we're looking for,. Otherwise we are all.

A

Going to have --, Michael and Jennifer,, then we have to move on.

N

≫≫ Just, a quick point,. We've now completed the wave 1 hospital.

N

Inspections and wave 2 is underway.

N

There was a very strong theme running across wave 1, which is A&E services.

N

Were almost universally a problem in every hospital inspected and CQC is.

N

Therefore, building an experience base in A&E,, which I wonder whether that.

N

Should be a thematic review, because we really are the only people that have that.

N

Extent of knowledge, and if we can do a review, which then says what best.

N

Practice is and how to get there, I think that could be very powerful,, so I think.

N

That sort of is a sort of thematic review that draws directly from the results of.

N

Our inspection process, now it's too early for adult social care and primary care.

N

Because we haven't started the new approach,, but where we have, there is.

N

Already this very powerful issue emerging and --, but I, don't know enough.

N

About healthcare,, maybe Camilla will tell me, I, just don't know, that there are.

N

X numbers of people looking at how to solve A&E,, but we certainly know a lot about it. Now.

K

≫≫ And, we will have done an out of hours report for urgent care and A&E.

G

≫≫ At the risk of opening things up. I'll, try not to too much, I, see the potential value.

G

In two areas, one, those things that no one chief inspector's area can do,.

G

So that's the cross-cutting element, which is built in and the other is doing.

G

What in clinical language would be a phase 2 trial before.

G

A phase 3 trial, looking at a particular area, but not across the whole country.

G

Because that could influence how we go about our full inspection, programme,.

G

If we learn things about nutrition for example,, as we've done in the past, that.

G

Could potentially influence how we then do all our inspections.

G

That's, where I would hope we might add value.

A

≫≫ Right I think we better move on,. We haven't come to a conclusion on this,.

A

I, don't feel, Paul, we're quite where we need to be on thematic inspections,.

A

The conversation -- we're just not all in the same place on this at all,.

A

So I'm going to suggest we re-think this a bit and bring back another paper to the.

A

Board in a month's time.

H

≫≫ Can I ask that there is a clear and limited recommendation from the.

H

Executive about what will make the biggest and best contribution that CQC.

H

Can make given everything else we're doing both in terms of our own business.

H

Planning and in terms of the major issues that we've identified because I.

H

Just feel we've opened up the list,, we've created a basket full of treasures and.

H

Every time we talk about it, we add more and we will always have that tendency to.

H

Do it, we've, given you some really clear criteria which we all like,, even if we're.

H

Not sure that they've absolutely been applied in every case about how we.

H

Want to you to select, we've, given you some more guidance today about how.

H

We'd like to you, do it, I. Just don't think this larger group of people is the place to.

H

Choose which ones to do.

A

≫≫ That's, where I am as well Paul.

C

≫≫ I'll bring you a list saying this is what we're going to do next year, next month.

C

≫≫ And why.

A

≫≫ This is great David. >> Why,, it's the impact.

C

≫≫ It's a really helpful,, genuinely helpful conversation and it's added to the.

C

Previous two conversations that we've had on this and I think what we'll bring.

C

You is a list of what we're proposing to do and why and when we'll begin and.

C

These challenges about why us and nobody else,, are we duplicating what.

C

Others have done,, how does it fit with the business plan are helpful, additional.

C

Points to draw out- and we will a bring you defined list of things- that we'll bring forward to do.

A

≫≫ Thanks very much, Paul. Yours is the next paper as well. If you have the energy.

F

≫≫ And a due sense of trepidation.

F

So this looks at our intelligent monitoring, but not the acute side where we.

F

Probably had more board conversations to date and a number of the other major.

F

Sectors,, adult social care,, primary medical services,, both in hours and out.

F

Of hours, mental health services and community health services.

F

Can I start by framing what we see intelligent monitoring as, only because.

F

It's become synonymous with this banding process and almost in the eyes.

F

Of the media, but not in the eyes of CQC, some sort of proxy for rating.

F

It absolutely isn't that,, as Mike said earlier, it serves a useful purpose in.

F

Guiding where we should inspect.

F

And, that's on the banding side, but also the wider process by which we use all.

F

The data available to give the best view on where risk is in the system for all.

F

Those days when we are not on site,, which of course is the vast majority.

F

And that's its real power.

F

So, the question we have been asking ourselves is: what level of specificity can.

F

We go to in the different sectors outside acutes,. We think there is no sector.

F

Where we can't produce useful analysis, intelligence to guide our inspection.

F

Judgement, just to put that out there, clearly in some sectors the data is less.

F

And in some it's more, but there is always enough to guide inspection.

F

The question that follows from that is,. Is there sufficient data to accurately band.

F

For the purposes of inspection, the level of risk, the priority for inspection,.

F

And this very much plays to Jennifer's question earlier about the volatility in the.

F

Acute intelligent, monitoring, we've had to ask ourselves the hard question,.

F

If we were to produce a banding in, say, adult social care,, would the knowledge.

F

That it gave us of where to go next, be outweighed by the number of false.

F

Positives and false negatives that would bring, and that's really the question the.

F

Analyst team led by Lisa, has been grappling with.

F

So, where we've come out to is that there is sufficient accuracy and.

F

Standardisation of data for the in hours, GP component,, but not for out of hours.

F

And there is sufficient in mental health, but there isn't sufficient data in adult.

F

Social care,, either residential or domiciliary care and there isn't sufficient.

F

Information in community health services,, so if I translate that,.

F

That would mean that there would be a banding for inspection that would cover.

F

Gps in hours and mental health,, as well as acutes,, but not for the other sectors,.

F

That's our proposal and the board is asked to agree the direction that we've laid out.

A

≫≫ Thanks very much Paul.

A

Any questions for Paul on this?.

B

≫≫ I wondered if you considered things,, for example, the financial situation in a.

B

Particular area or where there are major reconfigurations, because that often can.

B

Generate pressure on services and a dip in quality,, these are very specific.

B

Indicators about the service or the hospital, and I just wondered if there are.

B

Cuts, for example, that's going to impact on the quality of care, or an organisation.

B

Being in debt or major changes.,.

F

≫≫ Yes, to split that into two.

F

There is the specific question of finances within a particular provider as.

F

An example, and if I just go back for a second to the acute,. Only because we'll.

F

Follow the same broad approach,, both Monitor and TDA, do produce judgments.

F

On sustainability, including the finances of providers- and we do look at that as.

F

Part of intelligent monitoring,, but the second part- and there is no reason we.

F

Shouldn't also do that for other sectors.

F

The question, is a particular local health and care community, particularly.

F

Stressed or challenged?

F

We haven't tried to do that in the quantitative data associated with.

F

Intelligent monitoring, but we absolutely are trying to set it up through the.

F

On-Going provider management, relationship management, I mentioned.

F

As a component of the jigsaw earlier and we're looking to develop more of a local.

F

Understanding of, what's really going on to inform that.

F

What I, don't think it will be, is easy to standardise, I. Don't think it will be easily.

F

Able to compare,, because it's just extremely difficult and everyone gets tied.

F

Up in knots about whether allocation in a particular area is sufficient or not,.

F

But I think we can say there is a big reconfiguration of services going on in.

F

For example, the Stafford region,, we would need to therefore look carefully at.

F

The quality of care, as a result of that, so we can follow up on that.

F

≫≫ Good,, thank you Paul is that it, can we move on?.

A

E

≫≫ It looks very sensible,. The only thing is a repeat of a comment made earlier,.

E

Which is about? Are we in a position to produce any kind of roadmap as to.

E

When you think some of the data that aren't available could come on stream.

E

Working with the information board.

F

≫≫ We are absolutely doing that work, I'm, not in a position to say, therefore,.

F

Sector by sector, where things will come in,, but we lead as an organisation.

F

For the whole of the health and social care system on the roadmap,.

F

For unlocking the different data assets and I'm sure there is a better way of.

F

Putting that, that Tom Ward in our organisation leads on with Emma.

F

Rourke and we can bring back a paper on that, we've already produced papers.

F

For the National Information Board on that, and we can bring back a paper to.

F

Our board on what that looks, like.

F

Separately Emma Rourke and myself, and one or two others met with Tim.

F

Kelsy and his team last week or the week before last precisely to look at.

F

What we can do between our two organisations, NHS, England and CQC,.

F

To just drive forward this agenda of what data is missing sector by sector, and I.

F

Was pleased with that conversation was just how much of it was about adult social care,, so it wasn't --. Even though NHS England has a particular locus over.

F

The NHS, they weren't forgetting the importance of the care data as well.

E

≫≫ Our assessment of risk in different sectors by inspection should help to.

E

Drive the priorities of the data.

E

In other words: we are the only organisation that can see quality through inspection.

F

≫≫ That's exactly right and it's why Emma and Steve made the point about care dot data earlier, having that data, that's linked across primary and.

F

Secondary care and the full care dot data vision includes that on social care,.

F

It's my understanding,, it's just incredibly important, so we can get a better.

F

Understanding on risk.

D

≫≫ I think this is probably about as good as it could be at the moment,. My initial thought.

D

There is a slight sense in which the last conversation does apply here too though, I missed that entirely,. Don't worry, I'm not going to go through each.

D

Indicator in turn and pass a judgement on it,, but there is a sense in which we.

D

Are always, and for years this has been true across the NHS that we start out by.

D

Wanting to know the answer to certain things and we end up looking to see.

D

What answers are available and that determines what questions we ask,.

D

It's still a little bit like that, I. Don't think you could necessarily do any better than.

D

That,, but there is still a slight sense that the indicators are a composite of. What's.

D

Available, and you're fairly explicit that that's true.

D

So. There is a version of this which will be slightly more strategic,, reflecting our.

D

Five questions a little bit more clearly, being clear where each of these.

D

Indicators lines up with one of the five questions and then making it clear.

D

Where the gaps are, that would need to be filled before this process, over a few.

D

Years, would be completely satisfactory.

D

For example, you could say effectiveness is not very obvious,. Our service is.

D

Effective,, it's not so obvious,, but you have ideas about clinical audits,. You can.

D

Equally say nice guidance and its implementation,, so there are ways of.

D

Signalling, where this needs to get to in order to be a better overall picture.

F

≫≫ Absolutely right Louis, on 3.1 in the paper,, although we tend to dwell much.

F

More on the top bit of that pyramid,, which is the data that's already there.

F

And therefore it means we can use it and use it in a comparable way.

F

The whole point of us having the tier 3 indicators. That's the full set of indicators.

F

That don't even exist, it's the ones we would want lined up against the five.

F

Domains and which we want to work with the system to create,, so we're constantly prosecuting this,. What's the data we really can use for banding.

F

Purposes or for informing our inspectors of things to look at, at the same time, it.

F

Goes to Jennifer's question about looking to develop the where the data.

F

That isn't currently available should be.

A

≫≫ Thank you. Next paper is on fees. Consultation from you and Eileen.

F

≫≫ I think everyone wants to hear from Eileen.

E

≫≫ Paul is too kind as usual,, either by incredibly intelligent design or happy.

E

Accident we seem to have a theme going here today, which is about the.

E

Value proposition of the CQC and what we bring to the world- and this brings it in.

E

Part to summation around what we expect people to contribute towards.

E

Funding that value proposition.

E

I think the paper, I hope it outlines. What has been quite a lengthy and.

E

Challenging process for us to get to the point of recommendation to you, today,.

E

Which we would ideally like to conclude today in terms of the cycle of our.

E

Business process,, we realise it's rather late, but I. Think that's because of some.

E

Of the challenges in-built in getting to this position, and also to say we're also.

E

Mindful that for the coming year, we want it to be a process that engages you.

E

Earlier, gives you a sense of fees and how we approach them in the wider.

E

Funding area regime, the CQC,, so that process is beginning now with a view to.

E

Engaging you in late Summer,, early Autumn in substantial discussion about that.

E

If I just set the scene there and I'm sure Paul and I will be only too happy to take.

E

Questions from you on, what's put before you, Paul, in particular, I, say nodding at.

E

Him over there.

A

≫≫ Thanks Eileen.

A

John. You probably have a question on this?.

O

≫≫ I have quite a lot of questions, but I'm not going to bore you with all of them.

O

You'll be glad to know.

O

The feature that most worried me was the differential recovery rate for different.

O

Sectors,, in other words, we are basing our fees on the cost to us of inspecting.

O

Those particular services and those costs are very,, vary quite considerably.

O

From 39 percent of the actual cost for independent healthcare, single speciality.

O

Services, up to 100 percent for primary dental services,, although we're.

O

Recommending that be discounted also for adult social care.

O

And I just wonder how sustainable that process is in the longer term?.

O

I'm not --. Clearly it would be far too disruptive and delaying to try an unpick.

O

That now,, but I, do think for the longer term. It will re-open the issue that I've.

O

Experienced in the past from different providers saying, why is it that our fees.

O

Are calculated on a different basis from other sectors,, the NHS is being given a.

O

Softer ride or harder ride or whatever, and vice versa, traded, comments.

O

Now there are a number of complicating factors about this,. One is that some of.

O

The data is possibly questionable in its accuracy, and therefore it's probably.

O

Unwise to place too much reliance on it, and, secondly, these changes need to.

O

Take place over a longer term.

O

But. My plea would be that as well as doing this on an annual basis, there does.

O

Seem, in my view, to be a need for longer term harmonisation and in particular, I.

O

Find it difficult to justify or have found it difficult to justify why a private hospital.

O

Should be charged on a different, calculated rate from an NHS hospital,.

O

That's the obvious trade off, single service facilities are a special case,.

O

Wherever they are in the system,, but there are some anomalies and at some.

O

Point there does need to be a longer term calculation about how those.

O

Anomalies are removed from the system, I will leave all the rest of my questions.

A

≫≫ Thanks very much John, that's something we must pick up in the.

A

Autumn, when we look at this more carefully,, are people happy with the recommendation?.

J

≫≫ Just to make the point, I'm sure a lot of work has gone into this,.

J

I think we should recognise as a board that this is a difficult time for providers.

J

And it is a big ask to increase our fees,. We should be cognisant of that and as a.

J

Result be committing even more strenuously to offering value for money in what we do.

A

E

≫≫ Can I just perhaps offer reassurance,. We have a strong drive to.

E

Be thinking very hard about what the cost of delivery is in each and every one.

E

Of these areas and therefore, what is the value proposition that we bring? What is a.

E

Reasonable recovery rate in each sector and to have enough evidence to do that, sensibly.

A

≫≫ Camilla's point,. It is against a background when, if you take the adult.

A

Social care sector for example, they are being squeezed and squeezed and.

A

Squeezed,, it's really -- same for acute, NHS as well, but it's very, very tough.

A

That's the point: you're making, isn't it really.

E

≫≫ This is just a strategy: discussion, issue,, but I think we've got to address.

E

This issue in our strategic plan;: what's our long term game plan,, given the.

E

Squeeze will be on for ten years, we're in the sunny uplands of funding. As far as.

E

The CQC is concerned and we can't stay there,. How will we squeeze back in.

E

The longer term and what messaging we give out now in the next year.

F

≫≫ I was just going to make the point it links into the next item, in terms of the.

F

Uplift we're expecting from the fees, it's approximately 2 to 3 million more from.

F

The provider sector, and in comparison indicative uplift that we are expecting.

F

From grant and aid so from the Department of Health and the taxpayer.

F

Is £40 million, just to give a sense of,, as we produce our, to look to do things.

F

Differently and better, the additional burden we're placing on individual.

F

Providers through the fee structure is vastly less than the amount the taxpayer.

F

Is picking up through the Department of Health grant and aid.

H

≫≫ Small point,, but on the back of that, which is that I think it's really important.

H

Equally from the political perspective that it's clear that we're not using the uplift in.

H

Funds to finance the reduction in income from providers.

H

I think the £800,000 that we need to find to finance this change in the fees needs.

H

To be extra to everything else in the budget,, just as this is a change in the.

H

Budget plan for income from providers.

H

I know it's a small amount of money,, but I just think it's a principle that it's really important,, so it increases our efficiency challenge immediately.

H

And then we need to do more as well.

C

≫≫ So, we don't have to find £800,000,. What we'll have is an operating budget.

C

Next year of the income plus grant in aid and that's what will be distributed, so we.

C

Just need to be quite clear. A plan of what we hope to get is not the same as what we have been given and.

C

Allocating what we have been given across our budget is what we'll do,.

C

So I'm giving you comfort on the main point that you're making.

C

On the substantive point about where we're going in the future,.

C

The conversations have already begun with the Department of Health.

C

As part of this year's grant in aid settlement about what next year will look, like.

C

And the point about value, Camilla, that you are making and this issue about.

C

Where does this policy of full cost recovery lead us to,, because, in effect.

C

What we've got is a policy for the; if I can use this phrase, the old model of.

C

Inspection, not for the new model of inspection, and so it dramatically needs.

C

Reviewing so we've got something which is both consistent with the approach.

C

We're taking,, but also, as you say, with forecast for the next few years in.

C

Relation to what the reality of that will be,, so all those things are part of what we're.

C

Actually, currently taking forward.

A

≫≫ Thanks very much.

A

Business plan Paul.

F

≫≫ Thanks. So there was a previous conversation at board.

F

About this draft plan and we're now asking for agreement to publish the plan.

F

As it stands and is at annex A.,.

F

We've reflected the comments from the board, which are on page 4, showing those.

F

So, for example, the consistency check that was brought up between the.

F

Three-Year strategy and the two-year business plan.

F

Business plan is very much reflecting the fact that 14/15 is a transition year.

F

For us,, one where in a number of sectors, a significant amount of.

F

Our regulation will take place against the old model as we phase in the new model.

F

And, of course, with the regulations underpinning the Care, Bill and Social.

F

Care Act, coming in midway through the year.

F

But, the plan itself is seeking to set out, as you know,, the overall objectives,.

F

But the strategic measures and the operational KPIs and risks and set out.

F

What we expect our budget to be accepting that we haven't signed on the.

F

Dotted line as it were. But, the numbers are there,, 103 million, plus 120 million, so 223 million on.

F

Revenue and 50 million on capital,, that's our planning assumption underpinning.

F

The business plan.

A

≫≫ Thank you Paul. Anyone got any issues you want to raise in the business plan?.

A

Jennifer then Kay.

E

≫≫ Just a small point, on priority six, I, wonder if we can just increase the.

E

Profile of our idea about identifying good practice,, good examples,.

E

It's kind of there, but really bring it out a bit.

F

≫≫ We'll do that.

B

≫≫ The business plan from my perspective is fine, but it does need to.

B

Feed into our new performance framework,, it would be helpful to have.

B

An update and reassurance that, where we are with the new performance.

B

Framework and to know that, within that it will cover the business plan,.

B

So we know how well we're doing and are we delivering it.

F

≫≫ Again we can bring that back,. There are various pieces of work on-going.

F

There,, some of which were brought to the regulatory governance and value.

F

Subcommittee yesterday, covering the improved way of looking at regulatory.

F

Risk and assurance, we can bring back how the whole business plan and that.

F

Piece and quality framework knit together.

A

≫≫ Good, thank you: Paul. Any, other questions?, Nope.

A

Right;, performance, Paul. Still you I'm afraid.

F

≫≫ I'm sorry!.

F

So, this is January's performance and finance report,, although where we can.

F

We've updated it with the latest information.

F

If I, rather than try and go through it in detail,, if I just draw people's attention to.

F

Section 2,, the notable performance, and just the piece in bold I think is the main.

F

Bit to draw out, that, as of the 14th of March CQC, has completed its entire.

F

Inspection programme,, that's just under three weeks ahead of the year, end,.

F

I think congratulations should go to all our inspection staff,, but also supported.

F

By national customer service centre and intelligence and engagement.

F

People and our operational performance improvement people, our OPOS,. That's.

F

Quite a different position than the one we were on last year and in previous years.

F

The issues where we are off track are I, don't think news to board members,.

F

The reports within 25 days and registrations and variations of.

F

Registrations,, in both those cases, underlying issues are well understood,.

F

In registrations, it's the increase in volume and in terms of the reporting,.

F

It's about the complexity, particularly in NHS Trust reports, and on that second.

F

One we're looking, therefore, to set different and more graduated KPIs for.

F

The 14/15 year,, which are in the business plan.

F

The focus now in the remaining couple of weeks before the start of the new.

F

Year, start of the new financial year, is very much on operational readiness.

F

Which Hilary Reynolds is overseeing from the exec point of view, and if I.

F

Just briefly recap: their finances,. We are predicting £2.3 million revenue.

F

Underspend and £7.7 million capital underspend,, that's consistent with the.

F

Previous reports in the last few months, and the reason for that, as we have.

F

Discussed before is we're spending what's necessary and appropriate, and.

F

No more,, given that it's taxpayer's money and provider money,, and that as we go.

F

Into the planning for 14/15 with the Department,, we are being very careful.

F

With them to say, particularly on capital, this is our best view at the moment,.

F

But as our views develop and our plans solidify we'll want to keep having that.

F

Conversation, rather than getting into the sense that we bid for the most and.

F

Account for why we didn't spend it.

A

≫≫ Thanks Paul. Any comments on performance, I think we ought to note.

A

The fantastic work the inspectors have done and all the people who support.

A

Them in getting these inspections done at a time when all this change has.

A

Been going on,, it's been terrific, really, so easily to have slipped and they are.

A

Ahead of schedule,, it's fantastic.

F

≫≫ We planned to finish in week 49 and we finished in week. 49.

O

≫≫ David, you have said one of the things I was going to say so. I won't repeat: that.

O

Paul has said what I was going to draw attention to on the money.

O

But there is one question which hasn't been answered: yet, it's on page 4 of the.

O

Report and it's again a feature of these reports,, which I hope will change in the.

O

Future,, which is that they tend to report activity rather than achievement,.

O

And it is to -- the paper reports that 774 locations have had a warning notice.

O

Served on them,, which is an interesting piece of information,, but enforcement is.

O

Simply a means to an end, I'm, much more interested in what the end of this,.

O

So are there 774 people who have now complied with the warning notice, or is it.

O

774 minus some figure and if possible, could we have an indication of what.

O

That,, the product of the sum actually turned out to be.

F

≫≫ So: we will overhaul the report for the next financial year and we will say more.

F

About what the impact of those warning notices has been.

J

≫≫ Can, you just remind us,. Is it the next board meeting that we'll get the new version of this, I thought it was today,, but it's not is it, year end is March, 31st isn't it.

F

≫≫ I think we probably won't have the new one,. We won't be able to report.

F

Anything new for 14/15 for the April board.

J

≫≫ But in terms of the financial summary we will be getting a much more detailed summary?.

F

≫≫ Yes the full end year summary will come,. This definitely doesn't include it.

A

≫≫ The point Camilla is making is when we go into the new financial year. The.

A

Monthly financial reports to the board will be much more detailed than they.

A

Have been in the past, once we get into the new financial year.

F

≫≫ Yes, it won't be for April,, but yes, they will be more detailed.

F

A

≫≫ The NIGC,, poor Paul,. You have been volunteered for something else.

A

But. Thank you very much for doing that.

A

It's not --, it's got a limited time horizon this.

F

≫≫ Don't we all!

F

Yeah, it's until March 2015,. So that's right,! If I do the -- there's a paper around.

F

The approval of the new Chair, which is proposed to be me and the report back.

F

From the meeting that I Chaired as an interim,, if I just do those two things.

F

Together is that all right?.

F

So under the existing Terms of Reference, there is a non-executive.

F

Chair of the National Information Governance Committee,, which is an.

F

Advisory committee,, which was Steve Hitchins, who's, now left to Chair the.

F

Whittington, and David, chief exec, suggested I Chair that,. That was.

F

Discussed at the meeting with the committee and agreed, but it does need.

F

Board approval to that and to change the Terms of Reference accordingly,.

F

So that's requested.

F

As part of that March meeting there was also discussion about who should be the.

F

Deputy Chair, given that no deputy Chair had ever been nominated in the past, it.

F

Caused a problem when Steve left, there wasn't somebody who could step up as.

F

It were and John Carvell was nominated and unanimously agreed to that,.

F

I'm very grateful to John.

F

As regards what we discussed then briefly in the March meeting, there was.

F

A desire from the committee to just revisit its programme of work, so it.

F

Really did add the maximum value,. A lot has changed since the committee was.

F

Set up, a lot changed in terms of the way CQC is doing its business, and the.

F

Committee wanted to make sure it was positive and as valuable as possible in.

F

Discharging the legal requirements.

F

There are two reports planned, one for the first half of 2014 and then a.

F

Follow-Up report at the end of the current phase of the NIGC, which is March 2015,.

F

And the first report will focus very much on learnings from the initial waves of inspections.

F

There was a really helpful conversation amongst the committee about the key.

F

Lines of inquiry that we're planning to use in the acute Trust sector, acute.

F

Sector and how information governance plays into that, and it was noted there are.

F

A number of areas where information governance is included as a thing to.

F

Consider,, but there is no single key line of inquiry that nails it down. This is where.

F

You would look, I think we want to seriously consider that challenge,.

F

So the most likely key line of inquiry will be the second under well led,.

F

So we're in the process of looking at that recommendation from the committee.

F

We also had a good conversation about one of the pieces of work that would.

F

Happen prior to the main inspection, one of the pre-inspection processes, which.

F

Was around information flows and there the committee's view was: that was a.

F

Very helpful piece of work, but that it would be helpful to draw the distinction.

F

Between the willingness to share information that acute Trusts and more.

F

Broadly providers were exhibiting with the rest of the system,, given how.

F

Important, that was for continuity of care and also, as distinct from the availability.

F

Of good clinical information to guide the care within the hospital itself, and again.

F

We all reviewed the approach to be taken on pre-inspection around.

F

Information flows as a result of that.

A

≫≫ Thank you Paul. And, thanks very much for taking on that role,. It's much appreciated.

A

A

John. You were going to give a report back from the audit committee?.

O

≫≫ I am indeed, in order to assist the committee I prepared a written report.

O

Which was circulated,, while you were enjoying your dinner, I was slaving over a.

O

Hot computer and I thought it would be more helpful to have something in.

O

Writing and which would avoid the interpretation of what I have to say. Being.

O

Misconstrued or lost in the ether.

O

I want, first of all to say thank you very much indeed, to David and Hilary and.

O

Eileen, who spent a lot of time preparing for our meeting and a lot of time, actually.

O

At the meeting, answering our questions and explaining a lot of the detail of the.

O

Governance and process and the detail of the transformation programme.

O

The general conclusions that we have come to are two-fold,. The first is that.

O

On the first part of the programme,, which is the introduction of the new.

O

Regulatory regimes and inspection regimes for the different parts of our.

O

Overall sector, I'd like to echo first of all, comments that were made earlier in the.

O

Meeting about the huge amount of effort that has gone into delivering and.

O

Achieving those changes- and we were impressed both by the progress which.

O

Has been made against hugely demanding timescales and very.

O

Complex managerial tasks, and the conclusion is set out in paragraph five of.

O

My report, which says that basically, while not every specific goal, has been met.

O

Absolutely on time,, but we can assure the board that there is an effective.

O

Governance structure, which is concentrating on delivering the scale.

O

Of change needed and broadly on the timetable set,, so we can give you.

O

Confidence that those changes will be, have been and will be achieved over the.

O

Life of the programme.

O

That was the first conclusion. The. Second conclusion was on the second part of the programme, which is.

O

About changing the underpinning systems, processes, and the way in.

O

Which staff are managed and manage the organisation and the skills and.

O

Training and experience that they have in order to do their job.

O

We strongly support the development of the academy as a way of achieving a.

O

Step change in the skills and culture and approach of the people who work in the.

O

Organisation, and perfectly understandably, over the period so far,.

O

The academy has concentrated on equipping the new inspection workforce.

O

Whether that has come from inside the organisation or recruited externally,.

O

With the skills they need to carry out the inspection, programme.

O

But, that has perhaps inevitably led to a build up of skills and experience and.

O

Systems which need to be developed and changed and on which the.

O

Organisation depends,, which have not been addressed so far to any significant.

O

Extent, and which slipped back into the later period of the transformation.

O

Programme timescale,, and we feel this is quite a serious risk facing the.

O

Organisation and facing the transformation programme and.

O

Therefore, we have made -- we've not put ourselves in the position of trying to.

O

Manage the programme, we made two recommendations,. The first is that we.

O

Believe that the detailed deliverables are set out in the transformation.

O

Programme,, which are currently specified until April 2015,, need to be.

O

Expanded and developed urgently to encompass the change needing to be.

O

Achieved by April 2016,, so there is a clear specification of what the.

O

Programme is aiming for,, particularly in that second category, until the period at.

O

The end of 2015/2016.

O

Secondly, we believe that working back from those, it will be necessary to.

O

Devote greater effort to planning, this spring and summer,, what changes need.

O

To be made to systems and to staff development bringing forward the start.

O

Of these into the current, sorry into the financial year, which is just about to begin.

O

Now, this is a really big ask because, as David has said, before, the organisation.

O

Is running hot, people are working at maximum capacity and the most that is.

O

Huge amounts are being devoted to the progress which has been made and.

O

Needs to be made in the future.

O

But. It goes back to almost a question about why organisations, complex,.

O

Large organisations have developed the concept of the balance score card as a.

O

Way of managing their operations, and that is to avoid a situation where the.

O

Absolute priority to achieve some particular part of the organisation's.

O

Programme squeezes out developments and change and investment, which is in.

O

The end going to be just as necessary for that organisation's success, as the high.

O

Profile part, and therefore we have made these two recommendations to.

O

The board, and particularly to David that he should look at these, we've, not.

O

Prescribed exactly what the answer should be,, but we feel it's appropriate.

O

Given the need for this new structure of inspection regimes and regulatory.

O

Regimes, to be founded on a secure organisational base, and therefore we.

O

Recommend that bringing forward the planning and analysis that we've.

O

Recommended should take place.

O

I'm very happy to answer any questions, but in summary, that's what the paper says.

A

≫≫ Thanks very much John. Any questions for John?.

A

David, do you want to respond?.

C

≫≫ No I think the board asked John and colleagues on the SEGC to have.

C

Oversight of that,, so there was some scrutiny yesterday for this quite detailed.

C

And constructive, discussion, I think it's really helpful that John set it out in.

C

Writing to be honest, I'll. Do this with Hilary and Eileen,, but we've.

C

Appointed I think it's now out, but if it isn't, then Tracey Forrester will lead the.

C

Work that we're going to do on the academy,. That's a confirmed, position,.

C

So we'll now sit down and actually review this 16.

C

I think the balance that the board was trying to take yesterday is to have a.

C

Constructive conversation with us and by the same token we were trying not to be.

C

Defensive about what we've done., If everything's a priority, nothing is, and actually getting the inspections up and.

C

Running, people into new jobs was actually the priority.

C

Now the priority is making sure those people --. It goes back to the earlier.

C

Conversation, are supported to the job, we're asking them to do and have got the skills.

C

I think it's a really good challenge and and we'll do that David, and we'll bring.

C

Something back to the board or the SAGC in the next,. If you let us get into.

C

May then we'll bring it back in May. That gives us time to get over the hump of.

C

Everybody changing job in April and settle that down and we'll report on this.

C

By which time I think we'll have more people into some of the jobs we need to.

C

Create to allow us to get going.

C

Again I, don't want this to sound defensive, we've just not had people in.

C

Some of the jobs, we've had a conversation before about the risk. We're.

C

At for having no HR capacity,, we've now got Tracey Denison in,, Eileen's arrived,.

C

We're making progress in actually building that capability and capacity.

C

So we can tackle this at pace now,. In short, it's a helpful report and we can build on it.

A

≫≫ Good. John thanks very much.

A

Any other business?

A

We've driven the public out of the room, except for one person!.

A

Is there any question you're burning to put to us?

A

You're. All right are you? Well, done., Thank, you.

A

Oh. You do have one, sorry, I thought you were saying you didn't have any.

L

≫≫ An awesome responsibility representing the general public!.

L

Just one question, I come from an adult social care background and I'm really.

L

Interested in the learning that's taking place from the NHS inspections,.

L

Particularly that credibility has been gained through expertise and team,.

L

Those seem to be twoa crucial areas as well as data obviously,.

L

I'm just interested to know how the adult social care directorate is going to build.

I

On that learning,, because, from my perspective, working out, there, credibility.

L

For CQC is sometimes in doubt when there is not expertise about the.

L

Particular services being inspected, and just how is that learning going to be.

L

Embedded in adult social care, practice?.

M

≫≫ Thank, you very much. So the way that we're going to address that is, first and foremost by creating the.

M

Three individual directorates with a dedicated workforce focused on adult.

M

Social care,, that's part of it.

M

Second is within that, once we've got the management structure fully.

M

Populated and the support available in terms of managing those teams,.

M

To be having discussions with staff about what their areas of expertise, are,.

M

Not so that we kind of just focus people just in looking at learning, disability.

M

Services or whatever else it may be,, because there is benefit in actually.

M

Having a read across into other areas,, but to make sure that we're identifying.

M

Where that expertise is so that it can actually support. Colleagues across the field.

M

The third point goes back to things we spoken about at various stages through.

M

This meeting and David certainly has mentioned,, which is the support from.

M

The academy to work with our staff to enhance their understanding of the.

M

Services that they are inspecting, and also to enhance the understanding of.

M

What good looks like in those services, so being absolutely clear about that, and.

M

Using other organisations and other insight to help to us get there,.

M

So not thinking that we've got all of the answers internally, because we don't,.

M

But to bring that in. And, then the final point is also to say that the inspection team,, although many.

M

Of --, the consistent bit of that team will be our inspectors,, but we will also be.

M

Having our experts by experience, people who have had a personal experience of.

M

Care,, either because they've used services or because they've cared for.

M

Somebody using services.

M

Will be working alongside the inspector and to do the inspection, in the vast.

M

Majority of the inspections that we will do in adult social care- and we know.

M

From the work that we've already done, and some of the feedback that Mike's.

M

Already had, and Paul was talking about it only earlier in terms of the inspection.

M

Yesterday, having those people who really know what the questions are to.

M

Ask, and who can really get underneath the skin of the service, that we'll get that insight.

M

Over and above that, we'll expand the inspection team with specific specialists.

M

Where that is required, as informed by the intelligent monitoring and the insight.

M

That we'll get from the data,. So if, for example, there is a specific issue around.

M

Medication that we think that we should be looking at,, then one of our.

M

Pharmacists will go along. If. There is -- when we're looking at hospices,, as we will do from the adult.

M

Social care directorate,. We will absolutely be making sure that there are people.

M

Who are experienced and understanding of those services as part of the team.

M

So, it's a round package and I hope. That's given some reassurance,, but it is.

M

Something we're going to have to develop and learn from as we continue through.

M

An obviously pick my colleague's brains, as we go.

A

≫≫ Good,, you can pick it out over lunch with us as well. If you want to develop that further.

A

Last thing to say this is John, your last meeting, I, don't know if you'd forgotten that or not!.

A

But, you have seen good times and bad times, I think,. They have been difficult in.

A

All kinds of ways,, but can I just thank you on behalf of us all, really for sticking.

A

With us and for all the guidance, advice and work that you have given us as well,.

A

It's been hugely appreciated,, so thank you very much. John.

O

≫≫ Thank you, can I say just a couple of words?.

O

During my life I've had a variety of life goals and ambitions, but I have to say.

O

That until I joined the CQC, Chairing, an audit committee was not one of them!.

O

And, so it has been a new experience and a revelation to me.

O

But, it does give you an amazing perspective on the organisation,.

O

And I do just want to pay tribute to David Behan and his team and the staff of the.

O

Commission for their dedication and their commitment to the work that the.

O

Commission does,, but particularly to David and his team, for the change that.

O

They have brought about in the organisation, which I think you've talked about David as well.

O

It has been truly impressive,. I just want to say, I deeply admire. What's been.

O

Achieved and respect what's been achieved.

O

I have two brief words of advice for you, all.

O

That is I, think one should be careful to make sure that one under promises and over delivers.

O

Organisations that promise to deliver more than they have the capacity to tend.

O

Not to live very long.

O

And secondly, I think it would be wise advice to stick to the knitting,. There are.

O

All sorts of mission creep is imposed on organisations and sticking to the knitting.

O

Seems to be wise advice, given the scale of the challenge that you're facing.

O

So, thank you very much for giving me the opportunity of working with you. All.

O

Thank you for putting up with me, and thank you for providing at least two.

O

Chapters of my memoirs for the future.

A

≫≫ Thanks very much for those words John.

A

Good,, that's it., It's, lunchtime! Subtitles by Premier, Captioning, &, Realtime, Ltd., www.pcr.ie,.