Care Quality Commission Board meetings, 21 May 2014

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From YouTube: CQC Board Meeting 21 May 2014

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Agenda for the meeting of the Care Quality Commission Board, held on Wednesday, 21 May 2014:

1. Apologies and declarations of interest 0:01

2. Minutes of the meeting held on 16 April 2014 0:11

3. Matters arising and action log 0:16

4. Chief Executive's report 0:20

5. Chief Inspector of General Practice update 22:15

6. Chief Inspector of Adult Social Care update 40:44

7. Chief Inspector of Hospitals update 1:04:13

8. Finance Report: Quarter 4 1:23:48

8B. Performance and Risk report: Quarter 4 1:41:00

8C. New performance scorecard for 2014/15 1:58:27

10. Questions from the floor 2:02:26

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

A

≫≫ Right I think we'll get cracking if we can?

A

I've got apologies from Anna Bradley, who is away.

A

The minutes, everyone happy with the minutes, I wasn't here for the meeting,, but Michael you're happy with the minutes? Yeah, thank you. I think the matters arising are all picked up,, so David. Your report, please?.

B

≫≫ Thank you David, good morning, everybody.

B

This is really a report which is updating colleagues in relation to progress, we're.

B

Making,, so the first item is really about the transformation update.

B

And, the first to or three paragraphs are really updates on inspections,.

B

Publication of the handbooks, changes to the structure,. The progress we're.

B

Making on recruitment, the development of a new induction, programme,.

B

Which began in earnest this week, on Monday, and the fact that now a number.

B

Of the newly formed teams are actually spending time on away days really.

B

Focusing on their purpose and how they are going to achieve that.

B

Next paragraph on, second paragraph on page 2 is really something that I try to.

B

Put in my weekly message to staff, this week,, which is one of the experiences, is.

B

The gap between what we've committed to deliver as an organisation in support.

B

Of staff, and the reality of that arriving, we're in a recruitment exercise,.

B

All staff haven't yet arrived,. The academy is forming and begun to deliver,. It's not.

B

Fully up and running, what I'm trying to do is just make that issue transparent.

B

And acknowledge the work that many people in the organisation are.

B

Undertaking and the pressure that they feel.

B

I think the mitigation of that pressure is in the appointment of staff,.

B

The development of the academy,, but that hasn't yet arrived.

B

So we'll continue to make progress on that and look at how we can ease that.

B

The development work, which is continuing over this next few months, is.

B

Really about how we handle concerns, complaints and whistleblowers,.

B

Michael is looking at this through his committee and we continue to make.

B

Progress on that,, and that seems to me to be a hugely important issue,.

B

Not because of the debate in the system about complaints and whistleblowing,.

B

But because of the imperative for us to get this right as part of our work.

B

The last report from our audit and corporate governance committee on the.

B

Transformation programme made some recommendations around focusing on.

B

The underpinning systems and processes and management,.

B

And that's been built into the work that we're undertaking,, 360 degree feedback.

B

Is an example of that, I know, members of the executive team have now undertaken that and completed it, and are involved in discussions with the.

B

Company that are undertaking the 360 degree, feedback, and I think that's a.

B

Significant development and I have to say I'm personally very pleased with the.

B

Progress that we're making.

B

Then later in the summer, in July, we've got a further external gateway review of.

B

The transformation project, programme,, which will give us additional external.

B

Scrutiny and commentary on the progress that we make, so an important.

B

Aspect to the work on transformation.

B

Pushing on, significant event on the 14th of May, with the Care Act, receiving.

B

Royal assent,, the real focus of the Care Act in the media, has been about the.

B

Changes in relation to the NHS, I think the significance of this is it changes.

B

Significantly, the legislation around adult social care,, where the whole shift of the.

B

System moves towards promoting the well-being of people in the system,.

B

Rather than the 1948 mode, which was really about less eligibility in many respects.

B

So a significant development across health and care,, but also significant for us.

B

Next paragraph is really about regulations, and this is live work.

B

Cqc colleagues are working very well with colleagues in the Department of.

B

Health,, the majority of these are in Paul's area and are looking at the.

B

Regulations in some quite fine detail, the consultation on these regulations.

B

Has now ended, regulations are being drafted and we're working closely with DH.

B

What we've set out in paragraph 3 are the processes which need to be gone.

B

Through in Parliament for those regulations to be available to us for the.

B

1St of October,, so the fundamental standards will go into Parliament in early.

B

June, they need affirmative resolution and if nobody raises any concerns in.

B

That 30-day period they'll be in place to be available from the 1st of October.

B

You'll be aware that the duty of candor and the fit and proper person test was.

B

On a slightly different track than the fundamental standards and the.

B

Department's ambition is that they are also available for the 1st of October,.

B

But there is more work that is required on those standards and that's a subject.

B

Of some quite detailed work between Paul's team and the Department of Health's team.

B

So the work that's going on at the present time is really about what the.

B

Next steps are that are required to get those regulations through, and then the.

B

Work that we will need to do is ensuring that our inspectors and Rebecca's.

B

Colleagues in legal are aware of precisely what the standards say,.

B

And what they mean when they are actually applied in practice,.

B

Because from that date we won't be running under the old regulations,, we'll run under these new regulations,. So that's a significant issue,.

B

And this week the executive team were looking at what work we needed to do.

B

Where we can front load the development and training of staff, so that.

B

They're good to go from the 1st of October when these regulations come.

B

Into force- and there will be similar issues about how we can brief providers.

B

On the details of the regulations.

B

So, a lot of work still to do, but those two paragraphs are just raising the key issues.

C

≫≫ Just a quick question on the fundamental standards, you mentioned.

C

That work's been done between the Department of Health and Paul's team,.

C

I suppose what I would like to know is to make sure that the fundamental.

C

Standards will actually do what they were intended to do, and that will be.

C

Practical on the front line,, so it makes sense to patients and makes sense to.

C

Our inspectors and staff,, so it's about how are we and the Department of.

C

Health making sure that we keep it real,, because you can have people sitting in.

C

An office in an ivory tower making decisions and come up with something.

C

That actually doesn't do what was intended, just how we can make sure.

C

We keep it real for people who are going to be either delivering them,.

C

Inspecting them or receiving them?.

B

≫≫ And, you put your finger right on the debate. That's going on between.

B

Ourselves and the Department at the minute, how we actually keep that real.

B

And keep it meaningful and how, in many respects, it's true to what the.

B

Government agreed to do when they accepted Francis' Report and said they.

B

Would introduce an action plan in relation to this, and this comes down not.

B

Just to what the standards are and how they're described,! But what.

B

Enforcement action can be taken and what will be subject to criminal.

B

Proceedings,, this is a breach which requires criminal proceedings and.

B

What's a breach that would require civil proceedings, that's exactly the issue.

C

≫≫ It's about having a dialogue along the way,, not just when it's all decided.

C

And we then tell people, so it's whether the opportunity to have some.

C

Sort of engagement and dialogue, as it's going along really.

B

≫≫ I, don't think, there's any chance that there's going to be an engagement strategy between now and then.

B

There has been a huge amount of engagement with people, they've consulted on these regulations and standards,. It's been out,. It's now.

B

Come back, we're now in the end game of ensuring that they're drafted in.

B

A way of picking up the comments that have come through, in many respects.

B

What I'm saying Kay is this timescale between now and the 1st of October is.

B

Very tight, in terms of working days, it's about 45 working days, I think.,.

D

≫≫ So in terms of what we've done already on the engagement --.

D

Back in June last year we kicked off with the new start,, which went after it,.

D

We feel we have a pretty good view of what people are saying, in light of work.

D

That Robert Francis had done, the Department with quite a bit of help from.

D

Us then drafted the draft set of regulations,, which they then consulted.

D

On for I forget whether it was 6 or 8 weeks and then once they go into the.

D

House of Parliament, so they can be debated. If necessary,, we then put out.

D

Our guidance on how we would use those standards on registration and.

D

Enforcement guides,, all of which we will consult on,, we'll have quite a few.

D

Opportunities,, but the key bit for us is, we feel we understand from what people.

D

Have told us,, so if it's a question about, can we hold a provider to account,.

D

Through criminal prosecution for leaving a user of services in soiled sheets, then.

D

We're just not budging on the need to do that.

B

≫≫ Paragraph 4 is, you'll be aware that on the revalidation of doctors, there's a.

B

Requirement that any organisation that employs doctors needs to put in place a.

B

Revalidation, paragraph 4 is basically setting out that Nigel Sparrow, who's.

B

One of Steve's team, will actually be the responsible officer at CQC in relation to.

B

This function, and the process- -- apologies for the last sentence in this.

B

Paragraph which got rather scrambled,, but what I'm obliged to do is bring a.

B

Report to the Board and the regulations require the Board to have sight of the.

B

Process by which that responsible officer's work is taken, forward,.

B

And we'll bring a report forward in the next few months,, which actually will set.

B

Out what the proposals are for how we should deal with that in terms of the.

B

Doctors that we directly employ. There will be other doctors that work with us, whose revalidation will be done.

B

By their employing body rather than by us,, but there is a number that will be.

B

Done by us and Nigel will take that forward and his approval as that.

B

Responsible officer comes from I, think from Sally Davis and that authorisation.

B

Has come through,, so this is the beginning of a process that allows us to.

B

Put in place a revalidation of those clinical colleagues that we directly.

B

Employ,, but it's also flagging that there's a Board level deliberation required of.

B

That and I'll bring forward the further details.

B

The. Remainder of this report is really updates,. Morecambe Bay investigation.

B

Has begun and witnesses are now being called, one of our colleagues from CQC.

B

Is giving evidence there today.

B

David Dalton's review in relation to different models of hospital provision is.

B

Now underway, I was invited on to it,. The reality is that Paul attended two.

B

Meetings that have been held so far.

B

Our appointment processes, continue, Sally, Warren I, think, is a new name who.

B

Will join Andrea's team from next month, and Steve, Eileen and myself.

B

Interviewed for a deputy chief inspector in primary medical services on Monday.

B

Of this week and we've offered that- and those processes are just going through,.

B

Once we've got those clearances we'll publicly announce the name.

B

Then, the very last paragraph, David, is a slightly technical, thing.

B

We are on track to produce the annual report in accounts in terms of finally.

B

Signing those off, they'll come to the Board,, but I think there may well be a.

B

Gap between the Board and us sending off the report, I think this is asking for a.

B

Delegation to me to make those minor adjustments that will be needed as numbers come in at the end of the process of finalising the annual accounts.

B

I won't authorise any significant changes,, but these will be numbers that.

B

Change in a minor way, just so we can get the finalisation and meet the deadline.

B

So, that's the update report and a request just for delegation for.

B

The finalisation of the accounts for the annual report.

A

≫≫ Any questions for David on his report?

A

Can I. Just ask one question; on the Dalton Review looking at chains of.

A

Hospitals, we discussed last night at the dinner a little about big hospitals versus.

A

Small hospitals, delivering good care and efficiencies and what have you,.

A

Is there anything coming out of your inspections, Mike that will feed into the.

A

Dalton Review about the future size of hospital,, the optimum size of hospitals?.

E

≫≫ I, don't think we're there yet,, but as we do more, yes, we will look at what the.

E

Quality of care, as we see in large hospitals versus smaller hospitals.

E

But I think it's important to remember that we have deliberately skewed the.

E

Sample of hospitals we've looked at to begin with,. We have chosen to look at.

E

Predominantly ones which were high risk on intelligent, monitoring,.

E

Not exclusively,, because in wave 1 we looked at some that were low risk,.

E

So I think until we've got further down the line, we're not really in a position to.

E

Comment on that,, but when we are, we will.

E

And equally, when we are in the position,, when we've done enough hospitals.

E

Going through the Keogh re-review process, if you like, we'll see how some.

E

Of those have faired with buddying arrangements,, not that it's for us to.

E

Comment on those specifically,, but we will certainly have observed.

A

≫≫ The kind of issue is that there is evidence, isn't there, that the more you.

A

Do of a certain procedure, the better you get at it, and there are minimums below.

A

Which, if you go down it may not be safe to do that. Procedure,.

A

Are we picking up those issues?.

E

≫≫ A lot of progress has been made nationwide on that,. So, for example,.

E

Stroke services are one of the best example, vascular surgery is another,.

E

A lot of cancer, surgery, and I think one of the things that perhaps hasn't been.

E

Talked about enough over the last decade is how much centralisation of.

E

Complex surgery has actually gone on in the country and certainly if we were to.

E

Come across places that were doing low volumes of surgery for which there.

E

Is evidence that greater centralisation will produce better outcomes? We will.

E

Certainly, comment on that.

F

≫≫ Just one point on that,: sorry, if I contributed to a misunderstanding, last.

F

Night about it, I, don't think Dalton is just about big versus small,. For us one of the.

F

More interesting aspects is the whole issue of integration,. If you're Salford.

F

And you own, the community Trust, that enables to you do a lot more in terms of.

F

Discharge and logistics, and if you have --, if you're Valencia and you have your.

F

Primary care inside your secondary care,, it changes the model,, so I think those.

F

Are also issues that we may at some point have some insight into,, because I.

F

Think that's where the added value ultimately will come. From, isn't it?.

E

≫≫ And again just to say that we are committed and that all three chief.

E

Inspectors, to do doing joint inspections when it makes sense.

E

So, if a hospital has some care homes attached,, we will do, assess those at the.

E

Same time, and we will look at the overall impact that that's having or with primary.

E

Care, general practices that are managed by Acute Trusts.

E

So there are different models emerging and I. Think our approach is adaptable, so.

E

That we can look at all combinations.

G

≫≫ Just on that, in the end, the prize is a kind of integrated service and the impact.

G

On how we carry out, assessments is that, which could be profound,.

G

Is that it then becomes one about integrated care,, and this does go to the.

G

Heart of a kind of anomaly about how we do our work, sorry to mention it after.

G

We're doing so well in attracting people.

G

But. There is a sense in which the NHS or care system is trying to become more.

G

Individually, driven, more built around the person who receives the care,.

G

So that everything that happens to them is, the services are built around them.

G

And the totality of their experience is what we're trying to improve,.

G

But because of the way that CQC has been established,, it is based on provider.

G

Organisations,- and that is a fundamental anomaly, which at some point we will.

G

Have to turn to,. It may not be now, because we've had enough to do in.

G

Considering our model,, but it is an anomaly which we can't ignore and the.

G

Solution to it is that you have an integrated service,, so it doesn't make.

G

Sense in a way to be talking about how well your provider Trust carries out your.

G

Acute care,, if your longer term, community care is poor,.

G

So the acute provider does well,, but actually your care experience is bad.

G

Many of the services we're talking about, mental health is a good example, are highly integrated,. Multiple providers who are not even in the mental health.

G

Sector, and understanding their contribution, which may be crucial to the.

G

Overall, experience of the person, is also crucial.

G

And, of course, just to bring up the unmentionable bit of this,. In the end, it is.

G

The Commissioners, who are responsible for organising the totality of the person's.

G

Care,, so there is a kind of contradiction at the heart of what we do,.

G

Which is that we are trying to understand per individual experience, by looking at.

G

Their chopped up care pathway, and until we address that,- and maybe this --.

G

I must say: I, don't know exactly what this review is about,. It would be useful to know,, because it's been mentioned a few times. Now.

G

Until we've addressed that we will not be following the philosophy of care that we.

G

Are there to support.

H

≫≫ Thank you for writing my job description!.

H

One of the main reasons for taking the role on was to do precisely what you are.

H

Alluding that we should do, so I lead on joined-upness, integration.

H

And the way we're building the primary care model is to move towards that,.

H

But we've had to prioritise general medical practice and the care delivery,.

H

As you quite rightly say., So we'll be going into each CCG, local authority area,. We are now,.

H

Instead of just doing a public consultation on a hospital,.

H

It's linked to health and care services across the patch.

H

You'll see in my report, and later, something about joined-up children's.

H

Safeguarding services across an area, we're looking through what we're doing.

H

To look at mental health and with,, hopefully the recruitment of our new.

H

Dci, start to look at acute care linking out of hours, 111 and with Mike, walk in.

H

Centres and A&E, so acute care,. How do you define what a good quality.

H

Service is for an area?

H

Now. Inevitably, when I go to meet GPs, they say who is assessing the Commissioner?.

H

In a way, if you think about it, we're assessing the commissioning of.

H

Services through the provision.

H

And, my vision is the patient, family, carer right at the centre of everything. So.

H

That we encourage joined-upness and Camilla's examples are two or three of.

H

Many others around the world and in this country, we can learn from.

H

I do think we have a key role in helping to take that agenda. Forward,.

H

You're absolutely right.

A

≫≫ Just on David Dalton, Dave just said. We might ask him to come to a meeting.

A

To find out exactly what he is, doing, okay?.

A

Steve, your report, please.

H

≫≫ Thank you, I refer to the answer. I have just given on integration.

H

A couple of things just to highlight, because the report is there for everyone.

H

To read,, firstly, on recruitment, sad to report that Matthew Traynor, who is one.

H

Of our deputy chief inspectors is moving to another role with NHS England from.

H

The end of June and therefore,, whilst we're hoping we'll have the third of our.

H

Four DCIs in post by the second week of June, by the end of June Matthew, will.

H

Be departing, as a career move,, which we support him fully in doing.

H

The lead on integration, for me will move to Janet Williamson,, who is the DCI now.

H

For the central region, who has got a career of health improvement and taking.

H

Positive things within the health and social care forward, and we're.

H

Interviewing for a head of integrated care to work very closely with Paul,.

H

Because we see the themed reviews as being key to a lot of what we're doing,.

H

A diabetic one is in final draft form and makes really good reading.

H

So on recruitment, we're spending a lot of time interviewing and we're.

H

Interviewing fantastic people and it's very difficult to make decisions,.

H

But they are really,, really good quality, people.

H

Out of hours, we are now moving in towards the end of that first phase of out.

H

Of hours inspections, in the report, you'll see we're looking at moving onto the.

H

Second group,, the third group, even, and I, must say we're finding very good care.

H

Care has improved remarkably, since our ministerial review of out of hours care in.

H

2010 and we'll be bringing a report to the Board in July,, which is a review of.

H

That ministerial review and where we are with out of hours.

H

Despite the fact we celebrated great, outstanding,, although we're not rating it.

H

Outstanding yet of course, practice in the press,, it didn't stop. Some newspapers.

H

Reporting how out of hours care was poor,. We still don't quite understand why.

H

They did that,, it would have been nice to have had an interview to discuss it,.

H

But the report showed Cambridgeshire was turned around remarkably,.

H

As a result, I believe of a CQC visit last summer,, which showed there were.

H

Inadequacies and with great clinical leadership, we honestly couldn't find a.

H

Fault in what we saw.

H

That's very difficult when you're trying to find some faults, as well as celebrating.

H

The good, it was remarkable.

H

We've also seen some excellent care in Derbyshire, in Bristol and in the big.

H

Provider Care UK, which put a lot of effort into their out of hours, provider.

H

And you can see where they have been working for some time. The quality of.

H

Care has improved, they've got some sites where they are a little behind, but.

H

Those that are really motoring, we've been hugely appreciative of the leadership there.

H

We've started on the first wave of in hours, GP inspections,, we're learning a.

H

Lot from what's happening, on both in hours and out of hours, the key thing is.

H

About consistency, making sure the judgments made in one area are similar.

H

To another area for the same standard,, but of course we're all waiting for the.

H

Final part of the consultation on the handbooks,, so what we're doing now in.

H

Wave 1 will be adapted based on the feedback.

H

We're very pleased with the number of people who have attended both external.

H

Stakeholder events and also work with our internal teams and the feedback is.

H

Very positive on what we're doing, so we're encouraged by that.

H

I won't say any more because it's all in the paper.

H

F

≫≫ Just something struck me as we're sitting here,. You said a lot about things like medicines, management and so on,. What about diagnosis,.

F

How do you get at that? How? Do you --? Do you work back from -- if I'm thinking about cancer, for example,.

F

We know that 25% of all cancers are diagnosed in accident and emergency,.

F

We also know from various studies that a certain percentage of GPs appear to.

F

Be missing a lot of cancers;? Is there a valid way of us looking at the way.

F

Individual practices, diagnose, people,, I'm, not sure you've talked about that really?.

H

≫≫ Not, specifically about cancer, cancer, as you know,, Mike and I, have.

H

Been talking about cancer together for years.

H

There is a number of ways we're looking at, one is through the intelligent monitoring programme that Paul is leading on,. The second -- part of our.

H

Remit at CQC is also to encourage improvement,, so one of the benefits of.

H

Having a GP going on the visits is that, even though the confidence limits in.

H

Small practices of less than 2,000 patients,, it's difficult to look at reliable.

H

Data, one full-time GP would probably have 7 or 8 new diagnoses, a year,.

H

What we're trying to do is encourage GPs, in a way many practices are doing.

H

This but others have fallen behind, to review the new cancer diagnoses,.

H

Particularly if they're in A&E or made outside the practice, but I believe all of.

H

Us as GPs should be looking at all new cancer diagnoses as a significant event in the practice.

H

So, that's only a maximum of 8 a day,, but you can then look at, in detail,.

H

If the patient presented in a timely manner or couldn't get an appointment,.

H

Or if they got an appointment, how many times did they see the GP before they.

H

Were referred,, were they referred under the two-week wait,? We know some GPs.

H

Don't do that, many, do it a lot.

H

So. The data that Paul's bringing forward will help us to focus.

H

But it's to learn how to improve, and then similarly continuing professional.

H

Development of the whole GP team,, so people aren't turned away,. They look at.

H

Symptoms, people who come back three or four times they look more seriously,.

H

So part of the encouraging improvement is what we're trying to there with the data.

C

≫≫ I've got a few points, three actually.

C

The first, one is just to say I'm, very pleased that you're going to be bringing.

C

A paper on how we're going to inspect what you've called prison.

C

Services,, which covers immigration and prison, because actually they're a very.

C

Vulnerable group of people and I'm not sure, we've done it justice to date,.

C

It does say you're going to bring it in August,, but I'm not sure. There's a board.

C

Meeting in August,- so maybe it's September,, but it's good that we are.

C

Going to do a signposting, statement.

H

≫≫ Well spotted, I'll, be here on my own in August.

C

≫≫ Maybe, that was by design, wasn't it!

C

I'd like to know a bit,. You've started some of the inspections of GP.

C

Surgeries, I'd be interested to know how you're getting the views and experiences.

C

Of patients using the GP services and maybe local people as well,.

C

Local stakeholders,, how that's kind of starting to take shape?.

C

And then, the final point is about relationship with the GP community,.

C

It's clear: there's all sorts of myths out there about what CQC is demanding.

C

And doing, most of it is wrong. Frankly.

C

And, it seems to me -- when a new service population comes into.

C

Regulation, almost inevitably there's a bit of a backlash, because people think.

C

More work and you know,, it's not unusual,, but I just wondered if there's.

C

More to be done, there?

C

I'm not quite sure, exactly what,, but it seems to me one message really: is that.

C

Actually regulation could be very helpful for GPs, you know, in highlighting some.

C

Of the real challenges that they're facing, and actually the philosophy that we're.

C

Kind of stronger together is quite a powerful, one, and I. Think we've seen it.

C

In social care and we've seen it in hospitals,, it's just to get your view on.

C

That, because I know it's difficult,, it's a difficult context for you.

H

≫≫ I enjoy challenges, but I think part --. Going to your second question. First.

H

There is something about celebrating really good and outstanding. Practice,.

H

And as I said before,, even when we were talking about great out of hours,.

H

Care,, it was possible to turn that around,. So what we're trying to do with the press.

H

Both trade press and the national press, is work with them on stories,.

H

Whether they put the good news on the front page or not, is debatable,.

H

But we will carry on.

H

We're trying to engage more with social media because often people who,.

H

Particularly my GP colleagues, who have something to say, will say it there.

H

Last night it was about whether we allowed Beatles posters in GP.

H

Surgeries,, so we're not there about quality and taste,.

H

Although I think that is very good!,.

H

When we start to recruit, at the moment: Nigel, Sparrow and I, and now our DCIs.

H

Are spending a lot of time running around the country talking to local.

H

Medical committees, GP conferences, but there aren't enough of us,.

H

As we recruit, there will be more, and our inspectors are starting to do and their.

H

Managers, some more local meetings,, a lot of it is myth busting,. That's why the.

H

Blog and Twitter and things are helpful.

H

But the meetings, just talking to Chris Day,. He has been to a lot of the.

H

Engagement meetings,. The feedback has been very positive about what we're.

H

Trying to do about rating across different patient groups and feedback from the.

H

Patient groups has been hugely positive about the fact they're included,.

H

Particularly if you're talking to vulnerable groups,, it's very rare that homeless.

H

People get a say, and the fact that they're actually named in what we're.

H

Trying to do is something,, even though thankfully, relatively small numbers.

H

Hugely important, ditto people who have learning disabilities.

H

So we're trying to do that.

H

Going into your first part, with stakeholders, Chris Day and his team.

H

Through Paul,, as part of Paul's team are leading on that work.

H

I think one of the benefits is looking at the system rather than the individual.

H

And as we build this through -- individual service --, as we build this through CCGs.

H

What I believe we'll hear is we'll hear issues about the joined-upness in.

H

Mental healthcare for example, access to talking, therapies, crisis, intervention,.

H

We'll get that feedback, and then with Paul Lelliott and his team and Mike start.

H

To look at how we can make statements about joined-upness.

H

And, the final part was about saying difficult things about premises,.

H

One of the new regulations, as they all do,, includes premises.

H

Are the premises suitable to carry out the operation that regulated for,.

H

And clearly we'll make statements about that when we find it,.

H

As we will about other fundamental standards.

H

C

≫≫ Just could be clear. Are you talking to patients when you're doing inspections.

C

Are you getting their views and experiences?.

H

≫≫ Yes is the answer. But, how you do it in a valid and reliable way? --. My wife was in her GP when.

H

Cqc inspected them and she hid because she didn't want to talk to the.

H

Inspector, I'm sure quite a few other patients are probably going to do that as well.

H

So, it's talking to patient participation, groups, looking at patient journeys,.

H

But also looking at patients who use services- and there are lots of ways of doing that.

H

We are also doing a trial if you like, of experts by experience in half of the wave.

H

1 practices and not in the other half, to see what the benefit is and see how we.

H

Can improve that.

G

≫≫ Steve, I agree that it is very good actually that we've got health and justice.

G

On your report, each time,, because that is a previously neglected area of the system.

G

Can I just check that when we talk about health in the justice system,.

G

We're not just talking about healthcare? Because. There is much more to health,.

G

The population with a lot of health problems, and very often detained in an.

G

Institutional setting, where their health problems are either missed or.

G

Exacerbated in some cases.

G

And, so the issue is whether they are being held in healthy environments as.

G

Well, as getting access to healthcare, just to illustrate what I mean by that,.

G

Not only prison for example, but on release from prison,.

G

People return sometimes to an experience of mental health, risk,.

G

High risk of suicide immediately on prison release, to domestic violence,.

G

To alcohol, to drugs,, so the risks within the system,, the justice system,.

G

Are not just about the healthcare that they receive.

G

So, my question is whether you are looking at that?.

G

And, just very briefly,, if I can just ask you about; a little bit like Kay is asking,.

G

About what's available to you, so far, when you have done inspections in.

G

Relation to the data and whether you were able to get behind data from GP.

G

Practices by talking to patients?.

G

For example: if you, I don't know what the questions are, actually,.

G

But if the questions were, can you get an appointment on the same day when you want one,, which would be a typical question about general practice,?

G

The answer may well be yes,, but the experience of people and the effort you.

G

Have to go to get that appointment can be enormous, getting up early,.

G

Ringing on the dot of half past 8,, taking half a day off work in order to take the.

G

Callback,, there is much more to what the initial data might show and I just wonder.

G

Whether you've already got a feel for how that might be shown?.

H

≫≫ Thank you, on the latter point first, because it's easier with short-term memory, loss!.

H

The patient survey is really, really important, and that gives us a lot of.

H

Information and is sampled regularly and is published.

H

So that gives us an indication before we go in as part of Paul's information,.

H

Well, the intelligent monitoring,, so you can focus on particular issues.

H

If, you haven't seen the survey it's worth sampling. A few practices, have a look at.

H

Ours,, we all have issues, but it's how the practice learns and improves.

H

And talking to patients in the waiting room on the day, or as they're leaving.

H

The surgery is one way of doing that, and we're looking at how we can get a better.

H

Sample, because it would,, if you're only doing it on the day and they've, got two.

H

Weeks notice of when you go in, you might find there is more receptionists.

H

That day and more appointments,, so there are ways of looking at that.

H

Although, we are doing unannounced visits as well when we've got real worries.

H

I'm pleased you highlighted, both of you, the criminal justice system.

H

As, you know, part of my drive in healthcare has been for the most.

H

Vulnerable,, many of whom are in and out of prison and detention, centres.

H

Sue Macmillan,, who is my deputy leading on this, is also driven that way.

H

And we're about to do a piece of academic research with Northumbria.

H

University looking at domestic violence and using our visits working with chief.

H

Inspector of HMI, Constabulary and others,, and looking at particular areas,.

H

And then, if we find there are ways of when we go into GP surgery to ask about identification of domestic violence,, what are the issues, we'll be doing? That,.

H

As we do from the bottom, up, but the hand offs between prison, in prison care.

H

And GP care are a major risk, both for physical and mental health,.

H

And I think we want to develop our methodologies to look both ways about.

H

How we identify that., Good point.

F

≫≫ Last one very quickly., >> Very small,, just on the surveys, one of my relatives received a couple of.

F

Months ago, a giant survey about GPs in a letter which appeared to be nationwide.

F

From NHS England, he was quite cross about it because the way it actually.

F

Asked questions about appointments didn't really allow for the fact that some people have to go through the kind of tortures and I thought there is.

F

Presumably, a colossal amount of taxpayer's money was spent on that survey,. Why did they do that survey rather than us, and do we have access to that data?.

D

≫≫ Yes we have access to the data, I. Think it's historic. We do some surveys.

D

They do others, it's commissioned from the Department of Health.

F

≫≫ But we shouldn't be --, I mean the taxpayer just needs one organisation to.

F

Ask the question and share it,: don't they?.

D

I just, it struck me I, just thought, I'd, never heard about that survey in this room.

D

≫≫ No, it's certainly the biggest survey that was done in the NHS,.

D

The GP/patient survey is currently run out of NHS England,. We do a number of.

D

Other surveys so maternity, survey,, it's just in each case as things stand, the.

D

Department of Health commissioned different surveys from different people.

F

≫≫ But, yeah,, just the questions were not very well written if I may say so.

F

I think whoever does it next time might want to consult Steve on how they do it.

H

≫≫ Outside this Board,. As you are interested,, it would be worth us having a.

H

Conversation about how we influence it, yeah,, because we have questions we'd,.

H

Quite like to ask as well using it, yeah.,.

A

≫≫ I think we should move on. Andrea?.

I

≫≫ Thank you very much., Like Steve, I'll not go over everything in the report, because you've read it,.

I

But just wanted to highlight four key areas,. The first was on the wave 1.

I

Inspections that we'll have done, we've completed the 250 wave, 1 inspections,.

I

We have absolutely,, as David Behan keeps on reminding us,. We are learning.

I

By doing- and we have indeed learned during the wave 1 inspections,.

I

There have been some difficulties,, but some significant positives that we can.

I

Take out of it,, particularly in the more rounded view of a service that we've.

I

Been able to achieve through the inspection, process.

I

But, what we are finding from our inspectors, is that it is taking longer,.

I

And that the new approach to writing the reports and making sure that we're.

I

Presenting that information in a succinct way has been a bit of a challenge,.

I

So there's some considerable work for us to do in taking the results of the.

I

Evaluation of wave 1 into the changes that we need to make for wave 2,.

I

And that's something that we are working with: Paul's team from the policy.

I

Point of view,, Rachel, Dodgeson and others to try and progress that, and also.

I

To make sure that the training that we have in place for people for.

I

Wave 2 is more extensive and picks that up.

I

Secondly I promised you an oral update on the round table on covert.

I

Surveillance,, which happened on Monday of this week,, and it was very good.

I

We were joined by a wide range of participants,, including David Hogarth in.

I

The audience today,, who was one of our panel members, who gave a perspective.

I

On the use of both covert and overt surveillance in services,- and we did.

I

Have within the room, every flavour of view that has been expressed to us.

I

Since "A Fresh Start" was published last October, from people who think that we.

I

Should be doing it everywhere and yesterday, through to folk who are very.

I

Concerned about the use of cameras.

I

I've written a blog which was published yesterday, afternoon, just reflecting on.

I

Some of the key points that came out of the discussion.

I

In relation to CQC's use of covert surveillance, I think that there was a lot.

I

Of unanimity of view that this should be a last resort, and that we would need to.

I

Be using it judiciously in terms of seeking out evidence where there were.

I

Specific concerns that we couldn't unearth in any other way.

I

In terms of using cameras in other environments,, we were asking the.

I

Question what could CQC helpfully do around all of this?.

I

And I think again, there was a sense, from the providers, people who are.

I

Using services, carers and others within the room, that we, working with other.

I

Regulators,, we could helpfully provide some guidance and some insight into.

I

How we would use information that people presented to us and support for.

I

Providers in making sometimes quite difficult, decisions,.

I

So there's more work to be done.

I

But. It was a really helpful. Discussion, and I was very ably supported by a.

I

Whole ton of people from throughout the organisation,, including Rebecca's.

I

Policy team, the engagement team and the policy team,.

I

So we'll keep on coming back to that.

I

The third point was about the registered managers,. The Board will I'm sure recall.

I

The conversation that you had in September generated by David's report.

I

At that time,, because I was only attending in observer capacity at that.

I

Meeting, as I wasn't in post yet,, but we've been progressing with the project.

I

Looking at those locations which, at that time did not have a registered manager.

I

In post for longer than six months.

I

And, the most important news is that actually we have increased the numbers.

I

Of registered managers in post in those places,, that's what we want to see,.

I

That's the whole purpose of doing it..

I

We have issued fixed penalty notices to about a quarter of those locations and.

I

We are now progressing with this through our normal inspection process.

I

In terms of providing information to inspectors about registered managers,.

I

The length of time there's not been one and what we're expecting them to.

I

Do to make sure that there is one.

I

We've equally been in conversation with providers and understanding that of.

I

Course there are circumstances where it's very difficult to get a registered.

I

Manager in post, there's clearly turnover,. We can't magic these people.

I

Up overnight,, and so we have to be proportionate and reasonable in terms of.

I

Our expectations, and I think there's also a role and responsibility for all of us in.

I

The sector to be promoting the registered manager's role as an incredibly.

I

Important post and valuing that, in the way that we go about the work that we do.

I

And I do apologise about a third -- two-thirds of the way down the page,.

I

The paragraph that starts "Of the original 2,439 locations, identified...".

I

That paragraph should have come out, because it's actually the table up above,.

I

So I apologise for -- I was trying to clarify matters and perhaps only succeeded in.

I

Making it worse.

I

And. The fourth point that I just wanted to highlight was the Panorama programme.

I

Which occurred, obviously in between our last meeting and this, and I've, set out in.

I

Paragraph 2.5, the areas that were highlighted by that programme,.

I

Our focus and involvement in those homes and you've also got the.

I

Statement that we issued at the time, on the day of the programme and the blog.

I

That I wrote the day afterwards in response to it.

I

I think that the important things to say about that is that the care that was.

I

Shown on that programme was completely and utterly unacceptable,.

I

And we have been very clear that that is the case.

I

Also very clear that we need to be responsive to people,. Both relatives and.

I

People who are using services,, but also staff, in responding to the concerns that.

I

They raise, and that there are different circumstances in each of those.

I

Locations, but I think that one of the things that I am heartened by in terms of.

I

The information that I've had back from inspectors doing the first wave of our.

I

New approach, is that they do feel that they are able to get under the skin of the.

I

Services in a much more meaningful way, to pick up some of those signs and.

I

To explore much further, what is happening in terms of the culture,.

I

Governance, management and leadership of services,, which is where.

I

People feel that they can continue to provide care in an appropriate way and.

I

We need to be really rooting that out.

I

So happy to take any questions, obviously on all of that.

G

≫≫ Thanks very much,, just on the Panorama programme,, sorry to repeat.

G

Myself from last night, or even keep referring to last night when lots of people weren't actually there,, but we had a discussion last night about this in.

G

A different CQC setting, and without repeating all of that, I think that one of.

G

The main things that came out of that programme for me was the untapped.

G

Resource of families and family opinion,, particularly in spotting the early signs of.

G

A care home in difficulties, or staff behaving inappropriately, and our task I.

G

Think is to ensure that that resource is not left on the sidelines, and that's made.

G

--, you could say that's true across the entire care system, but probably particularly true here, because we are talking about a client group,, a group of.

G

People who are receiving care who may not be, because of dementia or some.

G

Other reason, may not be in the best position to represent their own interests.

G

Because of the enormous range and number of locations that might need to.

G

Be inspected and judged, and because all of that is true even before we get into.

G

The home setting itself where everything is magnified., So I, just don't think you have to have all the plans now, but I, think in the end.

G

Where we need to get to it with this, is a much greater concentration on the.

G

Reaction of families, and on the views of families and the early warning that.

G

Families might provide.

G

And, although I think that CCTV may help us, I do think that the benefit from.

G

Engaging families better will be much greater than the technological solution.

I

≫≫ And, you took the words right out of my mouth Louis, because that's the.

I

Connection to be made between the round table that we had this week on.

I

Covert surveillance and this,- and that was a message that was coming out.

I

Loud and clear from people like the Relatives and Residents Association,.

I

Your Voice, Matters and others,, which is that we do need to be listening to.

I

Families,, we need to be responding to the issues that they're raising and we.

I

Need to make sure that that insight,, through our intelligent, monitoring,.

I

Guides us in when we inspect and what we focus on when we do that inspection.

I

And in terms of the expectations that we're setting for services, so I think.

I

You're absolutely right,. The only other point that I'd make is that obviously.

I

There are many people who are using adult social care services who don't.

I

Have families- and we need also to be thinking about how we ensure that we.

I

Are getting the insight about services,, particularly for people who don't have.

I

Somebody who can speak up on their behalf, and that's where ensuring that.

I

Staff are listened to within the service is really important,. That's an expectation.

I

That we would have of a well led service,, but also that we need to be thinking.

I

About and reacting to the concerns that staff who are whistleblowers to us.

I

About concerns that they have is really important too, because they may well be.

I

The people who will raise that on behalf of folk who don't have a family.

G

≫≫ Can I come in just briefly on that? I agree with you. The point about people who don't have families is absolutely right,, although if.

G

We think of this as not just a CQC resource,, but as a public resource. Then.

G

Those people will benefit too,. So if there is a family alert, not just expressed to.

G

Cqc but publicly accessible,, then that will drive the care of the people who.

G

Don't have families to represent them, if you like, I'm calling for a kind of sea.

G

Change in how we do that, a real step up in the scale of what we offer to families.

G

In the way that they can represent their concerns,, it can be talked about as a.

G

Tripadvisor effect because it has some similarities, I'm thinking more of a.

G

Publicly accessible, universally available, but at the same time reliable, set of.

G

Opportunities for feedback,, which we would make use of,, but which also.

G

Would be available to people choosing a care home,, it would be available to.

G

People, to the providers of care homes themselves to know a little more about.

G

How people view their service.

I

≫≫ Thank you, and we are in conversation with Paul's intelligence.

I

Team and others to be looking at some of the services that already exist where.

I

People can indeed do that, like Care Opinion, which has grown out of Patient.

I

Opinion, Find Me Good Care,, which I declare my interest, that was developed.

I

By the Social Care Institute for Excellence.

I

There are a variety of places where people are able to leave their comments.

I

And thoughts, which we can draw in and use, the sad fact is however,.

I

Actually, people don't do it very often in adult social care, settings,.

I

Because of the concern that they have of the impact and, however anonymous.

I

You might make that and confidential. You might make that,.

I

People are concerned about how that might be used and how it might impact.

I

On the care of their loved ones,, so the other aspect,, which is our opportunity.

I

For people to share their experience with us, directly, is also really,.

I

Really important,, and that is something that I think, that we need to constantly be promoting.

I

The very last thing that I'd say is that when Steve is doing his listening, events.

I

In primary care,, certainly I have been doing these sorts of things for donkeys.

I

Years, and, however much you want to kind of talk about one aspect of the.

I

Service that you're regulating, people will come along and talk about other things.

I

As well,, we need to be making sure that we're making a huge virtue out of that.

I

And actually using those broader opportunities to gain insight from people.

I

Who are either using services, or indeed visiting or caring for people who are.

I

Using adult social care services, as well as primary medical services.,.

C

≫≫ A couple of things. On, the listening to families, which I absolutely agree. We have to do,.

C

But I think we have to be a little bit careful about using other families as a.

C

Proxy measure for people who don't have families very heavily involved,.

C

Because people who do abuse will be very aware of people's vulnerabilities.

C

And I'm, mindful of, I, can't remember the place, but there was another home that,.

C

A family uncovered abuse and put in a hidden camera, but other families were.

C

Very positive about the home,, so we just need to be a bit careful about that.

C

Just, going back to the covert surveillance, just to check how we're.

C

Going to take it forward when we finally settle on what we're going to do?.

C

Because there's two bits to it,: one is whether we use covert surveillance in.

C

Our methodology,, which could be hidden cameras or mystery shoppers,,.

C

That's I guess one aspect for us, and the other is: what do we do,, because some.

C

Providers, I know there is one provider that said we're going to offer families.

C

Cctv,, so it's a sort of opt in, as opposed to all being done all the time.

C

Everywhere,, which I doubt frankly would happen,, but it is likely that there is going.

C

To be the option,, at least in some places, for overt surveillance.,.

C

And I just, there was all sorts of things around that, dignity,, weighing up risk.

C

Benefits,, whether people have the capacity to make a decision,.

C

What's a proportionate, response, and I just wondered: are we going to.

C

I suppose we have to make a decision about whether we use covert.

C

Surveillance in our methodology,, but the other aspect about providers is,.

C

I guess would that be about issuing guidance and then following it up in inspections?.

I

≫≫ Thank, you very much Kay.

I

I agree with you about the caution. Points.

I

In terms of responding to your question,, we asked three very specific questions.

I

In the consultation on the adult social care provider handbooks,, so the round.

I

Table was part of that. On-Going engagement and involvement of people.

I

In getting views about that and once the consultation is concluded and we can.

I

Get all of that together, we will be coming to a considered decision and a response.

I

On that,, so that will be part of the feedback on the consultation.

I

Secondly on the overt surveillance,, what was quite striking I think from the.

I

Conversation that we had on Monday, and evident through other engagements.

I

And interactions that people have had with me,, not least via Twitter,, is that it.

I

Would be useful for us to offer some kind of guidance around this, taking into.

I

Consideration the issues that you've quite rightly highlighted, need to be.

I

Taken into account when people are considering this, but also I, think.

I

Emphasising that we need to be making sure that we're thinking about.

I

The purpose of all of this,, which is to provide safe, compassionate,.

I

High quality, effective care,, how do we best go about doing that? And there are.

I

Other issues that we would be wanting to see being put in place,, not least the.

I

Recruitment, training, development, numbers of staff and their management,.

I

Their leadership, and the culture of openness and inclusivity,.

I

Both with people using services,, but also their families and carers and the broader community.

I

So, it's got to be part of a wider picture.

I

But I think that people are very keen for us to provide some guidance,.

I

I'll be working with Rebecca and her team,, but also the -- I forget the proper.

I

Name,, the Office of the Surveillance Commissioner,, who has a code of.

I

Conduct around this as well,, and what we need to be making sure is, that is.

I

Joined-Up for people in these particular circumstances,.

I

So that's what we'll be looking at trying to achieve.

F

≫≫ Just on Panorama,. To what extent are we active in pulling out messages.

F

For local authority, commissioners in our work,, because that's clearly,.

F

And their contract monitoring?.

I

≫≫ It's a very important part of what we do, there's two aspects for the.

I

Relationship with local authorities,, one is,, as you quite rightly say, around.

I

Commissioning,, although, let's not forget that about half of the commissioning of.

I

Certainly, residential care is self funders,, although that is variable across the.

I

Country in terms of the levels of local wealth.

I

But, secondly, on a safeguarding basis, in terms of the local authority's.

I

Responsibility for safeguarding and protecting at all levels,, so not just the.

I

Ones that they provide, they're, providing the services for or commissioning the services for.

I

So we're very mindful of that, and working closely with local authorities is.

I

An absolutely key aspect of what I'm expecting the adult social care.

I

Inspection teams to be doing., So, we've organised the teams, so they relate on a local authority boundary to.

I

Local authorities,, so that there are lead management relationships between.

I

Local authorities and our local inspection teams.

I

Where there are concerns, and particularly where safeguarding alerts.

I

Have been raised, again, that is a very proactive relationship and, for example,.

I

Particularly in the respect of the Old Deanery and St. Mary's Court,.

I

There's been a lot of interaction between ourselves and Essex, County Council in.

I

Terms of each other advising on what's happening, our insights and.

I

Understandings about what's happening there,, so they can use our information to inform their decisions.

I

I think, as time goes on, we need to be making sure we're not duplicating effort.

I

Between local authorities and CQC inspections, that they are confident in.

I

Using the information that we've got, but we're also confident about using their,.

I

The things that they can pick up because they're there in a local basis as part of.

I

Our intelligent monitoring,, so it is part of a very significant bit of the working.

I

Relationship that we've got.

F

≫≫ That's all good, I was just thinking about almost a national profile and us.

F

Publishing stuff and being a national resource.

B

≫≫ I think one --. Do you want to say something about area profiles which I.

B

Think go in part to that,, but I don't think. We've ever summed the area profiles.

B

Into a national profile, which I think is where your question comes from,, so that's a good challenge.

I

≫≫ Yes, I think there are two things.

I

One as David rightly says,, representing back to local authority's Health and.

I

Well-Being boards and Local Healthwatch, what the picture is locally.

I

In terms of the services that we're seeing.

I

But, secondly, I think we have a real opportunity,, particularly with the state of.

I

Care report and I'm, taking the words out of Paul's mouth as he is nodding,.

I

Using the state of care report as a way to translate that information back and.

I

Say these are the things you should be looking out for,. This is what we're seeing,.

I

This is the good practice that we're seeing as well as the warning signs you.

I

Need to think about when you're commissioning services.

E

≫≫ We had done an inspection of a total of 49 Acute Trusts, I'm pleased to.

E

Say this week we will have passed the 50 mark,. They are now in progress and.

E

As you know, I won't go through it in detail, but 18 of those were in first wave,.

E

Now we've done wave 2 and into quarter 1.

E

I thought what would be useful in this report is just to set out a bit more about.

E

What happened,, particularly in the wave, 2 ones, where we have been routinely.

E

Rating Trusts,, as we go along, and publishing those ratings.

E

It is important to remember, though, that the Trusts we selected for wave 2 were.

E

Predominantly those which had been shown as high risk, but which we hadn't.

E

Already done, or they were ones that were Keogh re-reviews or a few in there.

E

That were also Trusts, who were aspiring to Foundation Trust status,.

E

So not a normal sample, if you like, of all the Trusts in the country, and of those.

E

Four have been rated as good, 7 have been rated as requiring improvement.

E

And one we rated as inadequate and has now been put into special measures.

E

We've also set out here for you how the good ratings, compared with the groups.

E

That they were selected from in terms of band 1 and 2 of intelligent monitoring.

E

So I think the exception here, if you like, which proves the rule, is the Homerton.

E

Inspection where this was a Trust that looked like it was high risk on intelligent.

E

Monitoring but in practice the inspection team found very good care and, in fact,.

E

Rated the A&E department as outstanding, but in general I, think there.

E

Has been quite a close correlation between the intelligent monitoring and.

E

What we found at inspection.

E

It's too early, yet to comment on the re-reviews of the Keogh Trusts,. All I can.

E

Say at this stage is we have re-reviewed, done the planned inspections of all 14.

E

So by July we should have the reports of all of those through and we'll be able to.

E

Bring those together.

E

We've been active in the mental health and community health service sectors,.

E

As well, again just listed the Trusts and I'm pleased to say that now some.

E

Reports have started to come out, the wave 1 reports. Clearly we were not even.

E

Attempting to rate, but I think we have learned a lot about the process of the.

E

Mental health inspections,, and also about the process for how we best.

E

Report on them, and reporting by core service,, as opposed to by location,.

E

So if you are someone with eating disorders,, it's probably easier to follow.

E

What we are saying about eating disorders across a whole Trust, which.

E

May be a large geography, than it is to report on every one of 100 different.

E

Locations,, where services may be provided from.

E

So, we hope that that is a more,, an easier thing for people to understand,.

E

Public to understand,, but obviously we would be very willing, hopeful that we.

E

Might get comments from any of you about those reports and how they are looking.

E

I have then listed the further Trusts that are either now being inspected or will be.

E

Inspected very soon, we're much the same stage with community health.

E

Services,, as we are with the mental health inspections with a couple.

E

Published and others coming imminently.

E

Alongside all this, of course, we have continued with our external engagement.

E

And particularly looking forward to seeing what we can do in terms of.

E

Intelligent monitoring for community health, services, I spoke with Andrea and.

E

Steve at the NICE annual conference and we have been doing a range of.

E

Other events with the Foundation Trust Network,, NHS, Confederation and others.

E

As listed, very happy to take comments or questions.

A

≫≫ Thank, you Mike, any questions for Mike?

A

F

≫≫ Could, you just say something about Heatherwood and Wexham, and how the special measures mechanism is working?.

E

≫≫ Yes,, so at Heatherwood and Wexham Park, first thing to say: is we.

E

Were very concerned about the quality of care, particularly on the Wexham.

E

Park site, the Heatherwood site is an elective site and was really quite different.

E

So we,, as per the plan,, we make the recommendation to either Monitor or.

E

Tda, depending on the Trust, in this case, to Monitor, about the Trust going.

E

Into special measures,, this was accepted, so they then actually put the.

E

Trust into special measures. There is a special circumstance here, which was that it was already, Frimley.

E

Park were in discusson with Heatherwood and Wexham Park.

E

Effectively about an acquisition,- and we were certainly very keen that putting it.

E

Into special measures shouldn't hold that up, should, if anything, accelerate.

E

Whatever support was going to be needed to get that Trust turned around,.

E

But since we put it into session measures, it has been confirmed that.

E

That acquisition is going to go ahead.

F

≫≫ Sorry,, at what point do we then reinspect, the new entity?.

E

≫≫ Well we're still working out our approach on that.

E

You will remember that Frimley Park we have already assessed, but not rated.,.

E

But, it's one of the ones that we are planning an early reinspection in order.

E

To be able to rate it, I think probably the easiest thing to do is to do an early.

E

Reinspection to rate that, before the formal merger and acquisition goes.

E

Ahead,, but also while we're there looking at the well led domain in particular,,.

E

To look at what their plans are for the leadership of the combined Trust,.

E

As it is proposed at present.,.

F

≫≫ Sorry,, so our rating will be for Frimley, not the whole?.

E

≫≫ We've rated Wexham,, we will rate Frimley and then at some point in the.

E

Not too distant future, we will need to go back, either to the whole combined.

E

Trust, or certainly to the elements at Wexham Park, we found to be.

E

Inadequate,, we will want to go back there early on to make sure progress has been made.

A

≫≫ Can I ask, have the people at Frimley Park seen our report now and.

A

Said my goodness... >> Yes. >> They still want to go ahead with the acquisition do they?.

E

≫≫ Yes they do.

E

To be honest, Heatherwood and Wexham Park shared the report with.

E

Frimley Park in confidence before it was published so that they were fully aware.

E

Of what was going on,, but since then, they have given every indication that.

E

They are planning to go ahead.

G

≫≫ Mike, I think you mentioned a key issue, which is whether the intelligent.

G

Monitoring corresponds to what you find at inspection and I. Suppose the.

G

Ideal thing would be that it does,, but doesn't tell the whole story otherwise,.

G

You wouldn't need the whole system.

G

I assume you're talking about Acute Trusts,. Is that also true of the areas.

G

Where the initial information, intelligent monitoring is a little thinner like mental.

G

Health or community services?.

E

≫≫ I'll hand on to Paul very soon,, but the answer is really. We can only make the.

E

Comparisons for Acute at the moment, because that's the only areas where.

E

We've got sufficient intelligent monitoring before we go on site.

E

So with the mental health inspections, for example,, we have not been able to.

E

Use intelligent monitoring really to help us select, which Trust to go to first,.

E

We've been doing that on the basis of local information,, combined with what.

E

We may know from intelligent monitoring,, but also largely doing it in.

E

Those Trusts that are candidates for Foundation, Trust, status,.

E

Where, clearly, we have to have assessed it before they can go ahead.

A

≫≫ Do, you want to comment on that as well?.

D

≫≫ I agree with Mike really,. It's worth saying. We started the intelligent.

D

Monitoring with the banding for inspections for Acutes in September,.

D

October and we did the second run and third run towards end of July,.

D

Whereas we won't do that for mental health Trusts until towards October, this.

D

Year,, it's just a different cycle,, so we don't have a comparator yet.

F

≫≫ I'm wondering what the internal process is for going back after an.

F

Inspection here and bringing data and comparing with the analytics people,.

F

Is there a big post mortem, that's done about how can this be low risk, but.

F

Actually, we found it as good and just learning?.

E

≫≫ What we are asking our inspection teams to do is when they go on.

E

Inspection to look very carefully at the intelligent monitoring and to work.

E

Through with the Trust, why that might be happening or why that might not be.

E

Happening, so, for example, if this has happened at one or two places,.

E

There are very high emergency re-admission, rates,.

E

Is there an explanation for that?.

E

Related to the patient population, service, they provide,, whatever it may be,.

E

So the idea certainly should be that on each of our inspections, all the risks and.

E

Elevated risks from intelligent monitoring should be fully considered,, so when it.

E

Comes back to the report, we have at least considered those.

F

≫≫ Is that then fed back to the analytics team, who can then calibrate.

F

And remodify their models?.

E

≫≫ The analytics team form part of the national quality assurance group that I.

E

Chair so they are hearing that discussion as we go through and they.

E

Are contributing to it,, yes, is the answer.

D

≫≫ And will also, for their reports themselves, have a section in future,.

D

Which sets out each of the elevated risks and risks that we previously talked about.

D

Through intelligent monitoring and explain what inspectors and analysts.

D

Had found, so we have that step and that's important for providers,.

D

Because, even though we have always been extremely clear that intelligent monitoring is not a judgment,, it's an assessment of risk for the purpose of inspection,, it does allow them say. This is why there has been an update and why.

D

There isn't dissonance between a report and intelligent monitoring.

F

≫≫ Are, they suggesting other indicators on the ground,, the hospitals, suggesting.

F

Other indicators that might actually improve our set?.

E

≫≫ I, don't think we've had any other nationally available data sets suggested.

E

To us,, but we're always open to suggestions on that.

D

≫≫ It tends to be more tweaks on the existing metrics, one we discuss a lot is.

D

What the metric around whistleblowing should be, no-one disagrees with the.

D

Idea of looking carefully at whistleblowing,. But how recent that.

D

Whistleblow is, whether the case has been closed, to what extent,.

D

Is where the discussion is.

A

≫≫ You've been doing this for ten months. Now, I know it seems years,.

A

And 50 Acute Trusts,, but when you go to FTN and the Confed,, what's the.

A

Response now to the process?.

E

≫≫ The response is broadly very positive,. We had a meeting with about.

E

100 attendees that was jointly done by the Confederation and FTN just a week or two back.

E

People are at different stages of course,. Some people are still learning about.

E

What the process is, some have been through, it, some are about to go through it.

E

We're in no way complacent,, we know that things can be improved, but I think.

E

Everybody, almost universal,, the view is, this is far better than anything we have done. Before.

E

The concerns that they have are the concerns that we have,, which are about.

E

Consistency, consistency, consistency,, particularly when it comes to ratings, so.

E

Making absolutely sure we know what we are assessing.

E

And that we are assessing it in the same way.

E

There are lots of examples of things that I certainly hadn't, thought of at the.

E

Outset,, so if you're assessing outpatient services- and you discover.

E

That a percentage of medical records are not available when people attend the.

E

Outpatient clinic,: what is an acceptable percentage of medical records not being available?.

E

And at what point do we say that is so bad that it is inadequate?.

E

And, those are things,, there's no right or wrong,, but what we do learn is that we.

E

Have to ask that question in every place we go in order to be able to be fair to everybody.

A

≫≫ So, the interesting thing is the response from an audience of 100 is.

A

Actually, they're coming up with things that are helpful rather than as it were,.

A

Resisting the process.

E

≫≫ I, don't think anybody has resisted the process,. They just want to make sure.

E

That our process is as good as it can be,, as do we.

J

≫≫ Maybe two quick points.

J

(Phone rings) I thought I switched this thing. Off.

A

≫≫ That's someone saying don't say: it!.

J

≫≫ Or pause before you speak!

J

>> I'd, set it at silent, but obviously it hadn't worked!.

J

The quick point is this, I think that when, it's a question. Really,.

J

When a report covers more than one hospital,, we briefly touched on this last.

J

Night, the Trust report, --, the key findings are at the domain level for the whole.

J

Trust, not at the service level,, so to get to the service level. You have to go to the.

J

Individual hospital, report, and I just wondered whether there should be more.

J

Service level, information in the Trust report,, because the Trust report,.

J

Although they are already around 20 or 25 pages,, it's nothing like the hospital.

J

Report,, an individual hospital report, which can go, I, think the John Radcliffe.

J

One was 99, pages., So, I, think there's a sort of a compromise here which I sort of felt the Trust reports.

J

Are slightly too short and don't have enough detail,, the hospital reports may.

J

Be slightly too long.

J

But Mike asked for feedback on the reports and that struck me on the Trust.

J

Reports, that often one really felt I have to go to the individual hospital report to.

J

Really understand, this, and I. Think it's because the Trust report is perhaps at.

J

Too high a level.

J

The second point was actually about Lewisham and Greenwich,.

J

Mike mentioned Frimley Park, which of course was our case of. Does all green.

J

Allow a hospital to be rated as outstanding?.

J

Well Lewisham and Greenwich is all "requires improvement", and so the.

J

Question arises,: if something requires improvement in absolutely everything is.

J

That hospital actually adequate or should it be rated inadequate?.

J

So a question for Mike really.

E

≫≫ First of all on the Trust level reports. Yes, I, do think they can be improved,.

E

I think the major emphasis we want in the Trust level report is obviously on the.

E

Well, led domain,, that's a Trust,. We need to make absolutely clear that the.

E

Different elements of leadership are reflected in the report and to a large.

E

Extent we're making sure what we have learned from the different approaches,.

E

The focus groups,, as well as the listening event and the interviews are all reflected there.

E

I think the easiest way in the Trust level report. To summarise the findings for the.

E

Different locations is to show the grids for each location, and that is something.

E

We are planning to do from here, on,, it's just taking a little time to get the.

E

Technology sorted out behind that,, but we will do that, because I think that.

E

Gives you a quick at a glance,? If you look at the Oxford report that will show you.

E

The John Radcliffe, Churchill, Nuffield Orthopaedic Centre and the Horton.

E

Hospital and within two pages you would have the picture and then you would.

E

Know: okay, I really want to delve into this hospital or that hospital. Because of what.

E

You've seen, so I think the grids will be the answer to that one. In summary, form.

E

I think there is the debate on --. If something uniformly requires.

E

Improvement or requires improvement with a few inadequates, should that be.

E

Declared inadequate overall, should it be therefore put into special measures?.

E

These are some borderline, decisions, I think there we felt that --. There were two.

E

Things about Lewisham and Greenwich report,. First of all, it's only a merged Trust.

E

For six months,, secondly, in terms of the Greenwich site in particular,, it was very.

E

Difficult to disaggregate any data,. So although we had intelligent monitoring.

E

For Lewisham,, because it had been a Trust in it's own right before,, we couldn't.

E

Disaggregate information from intelligent monitoring because Greenwich had.

E

Been a part of the South London healthcare Trust,, so we had a paucity of.

E

Hard data for that Trust,, which is reflected I, think you'll, find in the.

E

Effectiveness rating- we have just said not assessable at this stage.

E

So I think equally one of the main things that we judge as to whether someone.

E

Will go into special measures, of course, is the leadership, and we didn't feel that the leadership merited that for Lewisham and Greenwich.

E

≫≫ Thank you. >> Thank, you very much Mike. Eileen?.

K

≫≫ There are three principle: chunks or bitesize pieces is perhaps a better way.

K

To describe them, I wanted to go through.

K

The finance report that you have grown accustomed to seeing- and this is the.

K

Last time you will see it in this format, so to just have a look at that.

K

To look at the way we have come back to you with a representation of contracts.

K

Over a value of £100,000, to set that out and then finally, to just note that we plan.

K

To bring to public Board that which we do regularly already,, which is to present our.

K

Expenses and expenditure on expenses and to do that in public format, every quarter.

K

So to go to what I say is the presentation of the overall finance report.

K

In this format,, the reason for saying it's the last time in this structure, because it.

K

Is reporting on what is a legacy structure for CQC and as of the 1st of April, we.

K

Moved to three inspectorates, plus customer, corporate services, strategy,.

K

And intelligence and future finance reports will report in that way and reflect.

K

The fact that we want all our directorates to have a high degree of financial.

K

Accountability themselves for their own performance,. So although there will be a.

K

Cumulative report- that's just to talk about the way we plan to operate in future.

K

The finance report, as set out, will see us to close the 13/14 year and actually.

K

Pretty much in line with what we have been forecasting for some while now,.

K

We're very close to achieving a balanced budget,, we'll have a slight underspend.

K

The area, which you may hone in on, and indeed we are honing in on- is the.

K

Underspend in capital budget,, which is very significant, and it's significant for.

K

Good and defensible reasons,, which is that, when you are in a period of very.

K

Significant change,, as we have been, it's very hard to make planned or productive.

K

Decisions about capital investments that you want to make or need to make.

K

We are now, as we are in 14/15, looking very carefully at the capital investment.

K

We want to make,, we understand what our expenditure envelope is, and we now.

K

Have some capacity and some experience to talk particularly about what.

K

Other systems we need to invest in that will allow us execute our work rather.

K

Better, so we hope very much to bring our expenditure in 14/15 much closer.

K

To a full spend. As ever we are not going to spend public money unless we have good reason to.

K

Do so, so the underspend, I, think,, I, hope I've explained and the future look.

K

So I will pause, there. I hope there is explanation. As I say this is a rather legacy based representation of expenditure, but it.

K

Shouldn't bring any surprises to the table.

K

It's been consistent with what's been reported, I think for the last few months.

K

So any questions on that particular element?.

F

≫≫ Just on the overspend, I'm, always more interested in overspend than underspend.

F

You've explained in the notes that the central overspend is really about legacy.

F

Pension fund,, which is fine. Are. We going to have detail going forward on pension liabilities, when you.

F

Produce the new financial reports?.

K

≫≫ We will do Camilla, our issue in not being able to report monthly or quarterly.

K

Is that very often we are spending a lot of time seeking the information around.

K

Them ourselves from the pension funds to actually understand with clarity. What.

K

Our liabilities might be,, we are actually coming to a much better position of.

K

Having far fewer pension funds that CQC is dealing with, and that will make.

K

Life easier for reporting in the future.

G

≫≫ It's also a moment to ask about the strategic risk register which proceeds.

G

That in the papers, it goes ahead of the finance report.

K

≫≫ I will attempt to take questions, I, wasn't necessarily seeing the two.

K

Together, Louis but...

G

≫≫ Are they coming up somewhere else?.

K

≫≫ I know they follow on. >> That happens, first.

G

I just wanted to ask whether we're seeing any of these risks going down?.

G

Because there is a slight risk of us becoming almost desensitised to the sea.

G

Of red that we see, here, I just want to check that,, presumably where we look.

G

At impact against likelihood,, the impact will always for some of these things will.

G

Not change,, because if they go wrong they will still have the same terrible.

G

Impact, but the likelihood presumably can reduce over time because of the.

G

Actions that we take, I just wanted to get an idea of the trajectory for what are.

G

Otherwise, quite a large number of red risks, and in fact, the ones that aren't red.

G

Are amber,, so nothing is green.

K

≫≫ I'm, not surprised by the numbers of reds and ambers that we have.

K

In terms of the moment in time that we're at,, where we have changed.

K

Almost everything in the organisation,, if we were projecting green I, think you.

K

Would be very legitimately saying we are not taking a real world view of the.

K

Reality that we live. The proactive management of the risk, though is...

K

>> Just, whether the trajectory is... >> The trajectory, is very much that we are moving red to ambers,. We have.

K

Some reds, which are stubborn, and we are working very hard on those and.

K

Putting resources at them, where things are amber,, the majority of those that are.

K

Amber are actually the trajectory is towards green, rather than back up to red.

K

But we have a very live and dynamic environment with so much change in.

K

The organisation, that it's best to be realistic about that and to provide.

K

Assurance that -- discussions about risk happen not just daily, but actually in the.

K

Hour,, in almost all the work we do here about what is the risk involved with what we're doing.

B

≫≫ If I just add to that, it's the next report, but I'm. Happy that all the difficult.

B

Questions go to Eileen before I present this bit,, but on this the audit and.

B

Corporate governance committee are the body which is a subcommittee of the.

B

Board with the added members that they have on it as well, that will actually.

B

Go through this risk, register.

B

I think Eileen's. Answer to your question about trajectory. Louis was the right one.

B

I think where I'd answer that, you're right to pick up on the likelihood,.

B

Are these going to happen and do we become inured to this and somehow stop paying attention to it?.

B

So I think the vehicle to have the detailed debate on this is the audit and.

B

Corporate governance committee and it does go through this.

B

If you remember, John, just before he left presented quite a detailed report,.

B

Which I flagged when I presented the chief exec's report about the next stage.

B

Of the transformation programme needs to pay attention to systems and process.

B

And investment in staff, that was as a result of that committee spending about.

B

An hour and a half on the transformation programme and many of these red rated.

B

Risks are derived from the transformation programme.

B

So, just the first one,, our revised systems, don't pick up risk and then.

B

We're criticised because, having said our old systems have not been effective, we.

B

Introduce new systems and they're found to be wanting as well.

B

We have just spent, as a Board, an hour going through with Mike, Andrea and.

B

Steve, what are these systems like,? How robust are they,? Do they work,.

B

Do you get under the skin?? Which has been a further scrutiny if you wish of.

B

Sp1, that first risk, about whether the systems are right.

B

But, because this is May of the changes as Mike said,, he is in quarter 1, Andrea.

B

And Steve are in wave 1,, not even in quarter 1,. We are still developing these.

B

Systems, I think Jennifer's question is about. Are we now triangulating? What.

B

We're getting from intelligent monitoring back with the results of the inspection,.

B

Your question about, where are we in relation to intelligent monitoring for.

B

Mental health, really do just reinforce the point that we're not at any.

B

Sophisticated stage of maturity in developing these systems.

B

Paul was questioned,, we've been doing it for ten months, and yes, we have been doing it for ten months,, but eight of those ten months were piloting and.

B

Doing it so I think it would be premature to start shifting some of these.

B

Likelihoods from where they are, which is 3s, into 2s and 1s frankly,.

B

I just think it's too early to do that.

B

I think when we get into October and the autumn of this year,, particularly on.

B

Those things that were into our quotas for Mike,, less so for adult social care.

B

And primary medical services,, then I think my ambition would be that we are.

B

Beginning to shift those 3s to 2s, some of those reds to ambers.

B

Personally I'm not of the view that we'll start moving some of those ambers truly.

B

To greens during 14/15, I think 14/15 year is really a year of embedding this,.

B

This is what I was trying to say in the gap where our staff perceive.

B

We've got some teams that should have 8 people in them, they've two and a half people in them,, so they're carrying a full workload,. So our promise of.

B

You'll have caseloads of 40 or 30 were between that space, we're not delivering.

B

And we won't deliver that until later this year, in some cases.

B

So I don't think we have stopped noticing these or stopped doing these.

B

I think the whole of the conversation this morning and very.

B

Often, when I present, the chief exec's report and the three chief inspectors.

B

Present their report, the questions you're asking are really about that risk.

B

Register without discussing the risk register in that sense, and if you just run.

B

Through it, I think they're the questions you have been asking.

B

But, my sense is: we've done fantastically well over the past 12 months,, but gosh. It's fragile.

B

We express that we've done a lot and there's more to do,. We have done a lot,.

B

I can't speak too highly of the efforts of my colleagues and every single member.

B

Of staff in the organisation,, but gosh there's still a lot more to do.

B

So I think these are about right,. So that's where I'd go with it,, so keep asking the.

B

Questions and let's look at October, November and then next March and.

B

Keep asking that question of have we got these trajectories right,?

B

Are they going in the right direction,? Should they be coming down?

B

But personally, I wouldn't argue to start shifting SP1 from the likelihood of that.

B

Happening into where we're assessing at a medium risk, I wouldn't want to make.

B

That a 2 or 1 personally. I think that's what the Secretary of State was saying to us last night,. He said in a.

B

Different way this year is about delivery and we need to support the staff to.

B

Deliver and we're not there yet.

A

≫≫ This will come back to the audit. Committee, won't it?.

A

≫≫ It comes to the audit committee to every single meeting of that committee..

A

≫≫ Does, it come to us twice a year?.

K

≫≫ It should come in summation once a year, but we can certainly bring it.

A

≫≫ Quarterly is it?, I. Think Louis' underlying point is we'll get used to looking at it. If we're not careful,.

A

It's better, it comes infrequently and we can see if there is any change or not.

K

≫≫ No, indeed, that's a very fair point, thank you.

K

So, can we just move on to the consultancy spend which is presenting.

K

To you, contracts over £100,000 that were let in 13/14, and that represents, as.

K

Is show here,, 96 percent of the spend,? Actually 94 percent of this total spend.

K

Actually came from our transformation budget,, so what I hope it's setting out is.

K

A pattern that purchasing consultancy support at this level is not normal activity.

K

For the organisation,, it is actually linked to the changes that have been made,.

K

So the contracts set out here do have explanation around them in terms of.

K

What they were for, and they have been closely and tightly managed to make.

K

Sure that they come in on budget with requirements fulfilled whether there has.

K

Been a need for proactive contract management that has happened,, but we.

K

Are not going to be spending as much in 14/15 because we are in a different.

K

Phase of the organisation,, but certainly if you find it helpful, we can bring a.

K

Quarterly report on consultancy spend to the Board above a de minimus level if.

K

That would suit you.

K

Also to note what I think is important, just a slight variation to what we have.

K

Been doing, all our contracts,, although you would have to look hard for them.

K

That we let, are actually on the Cabinet Office website, so they are open and.

K

Transparent to all. We just decided it's much easier for people to navigate who are interested in.

K

Such matters that we're going to put all the contracts that we let, up on our own.

K

Website also,, so there will be a way of navigating straight to contracts that we.

K

Let from our own website, rather than having to go through the Cabinet Office,, so that's happening with immediate effect.

K

≫≫ So we're saying we'll put every quarter.

A

≫≫ Every quarter. We can bring this back if the Board would like to see it.

A

≫≫ I think we should definitely do that. Any questions on the consultancy, contracts, no?.

K

≫≫ Great. And, then the final piece again, which is something that I have been reviewing.

K

Since I arrived,, because as David would say, I'm a very sad person, is to look at.

K

Our expenditure on expenses right across the organisation and what again.

K

I'm proposing it would be good practice to do,, is to just bring in tabulated form.

K

Again, quarterly, expenditure for the executive team, around expenses and.

K

Then I think we'll also aim to bring expenditure more generally on expenses.

K

To the Board at least, twice a year.

A

≫≫ You were thinking of doing it on a monthly basis.

B

≫≫ Let's settle, I think this is in the interests of transparency, -- I think the.

B

Issue is on both consultancy contracts and expenses,. This is about.

B

Transparency,, it seems to me that if we don't put them out we're going to get.

B

Asked for them and then it looks like it's being dragged out of us,. So the only way.

B

To deal with this is make a virtue out of being transparent, I. Don't think we have got anything to hide in what we've done in either consultancy or expenses,.

B

So I think we should just make it part of the routine business to report them.

B

Publicly, so that colleagues, non-executive colleagues, can scrutinise.

B

Both the contracts and expenses, but also because these are public meetings.

B

And we report in a public way there is no mystery or secrecy about these things.

B

For, a large national devolved, decentralised organisation, where senior.

B

Managers need to be visible, I, don't think these are difficult. Expenses.

B

Similarly I think the way Eileen presented the consultancy which is 92.

B

Percent of this spend is really about bringing in the capability to make sure.

B

That we can make some of the changes, I think there's an explicable narrative to.

B

That, 5.8 million is a lot of money, no two ways about it,, but our purpose in.

B

Bringing in the capacity was to do the work that we needed to do.

B

So I think there is helpful explanations, people outside of CQC will determine.

B

Whether they are satisfied by those but the way to deal with, it is just to make them transparent.

B

So the issue is: what's the frequency we need to bring these to give that.

B

Transparency, rather than allow people to raise questions?.

B

These kind of things come quite regularly,, we're making spending.

B

Decisions,, incurring expenses on a monthly basis, so you'll get a monthly.

B

Finance report, so it makes sense to build it into that.

K

≫≫ We can certainly do it monthly if you prefer that, I'm, just going on the practice.

K

Of other boards,, where it comes quarterly,, so I'm happy to take it either.

K

Way, depending on what you like, really.

A

≫≫ Any strong, feelings? No, we'll think about it, more, no later than quarterly, but possibly monthly..

A

≫≫ Okay thank you.

K

≫≫ Thanks very much.

A

David you're doing performance?.

B

≫≫ I think Paul might help with this and our chief inspector colleagues as well.

B

So I think this speaks to the point. Eileen was making,. What we're doing here is.

B

We're presenting the final quarter of 13/14,. The next agenda item is how we'll.

B

Present both the finance data and the performance data for the year that we're.

B

Now in, 14/15,, so this effectively is the last of the years.

B

And the way we'll present these reports at subsequent meetings, David, is that.

B

I'll do an overarching presentation,, then each chief inspector or executive.

B

Director will speak to their bits in terms of the detailed questions,. It's a change.

B

Where Paul;, because his team put these together, has been presenting this and I.

B

Think, that's probably better distribution of the accountability for the work rather.

B

Than Paul's team that are drawing it, together.

B

So coming to item 8(b). The overall summary report pulls out what the.

B

Noticeable performance highlights are during the year, in terms of the.

B

Inspections, I'm not going to present it, I've, touched on some of this in the chief.

B

Exec's report,, but the completion of the programme, publishing of documents,.

B

Creation of new executive teams, delivery of the transformation.

B

Programme,, launch of the academy are some of the things that we're pulling out there.

B

Paragraph 3, we've pulled out and probably given more commentary on.

B

Those things that were set out to achieve in the year that we didn't, registrations.

B

Within eight weeks, second opinion appointed doctors and final inspection.

B

Reports, all missed for different reasons,, the performance ambition that was set.

B

At the beginning of the year,, Louis has already invited us into a conversation on.

B

The strategic risk, register, and I think we've had the discussion about this is.

B

Flagging the risk,, but it will be premature to start shifting those risks and we'll.

B

Report on these in the future and then the last bit, touched on to a certain.

B

Extent in the finance report in paragraph 5, is the progress on the transformation programme.

B

If I could just very briefly and finally invite colleagues to look at page 2 of the.

B

Slide pack and I think you'll see effectively in terms of our operational.

B

Services, inspection and registration slides, effectively 4 to 12, set out our.

B

Performance against adult social care,, the NHS, primary medical services,.

B

In terms of inspection and our performance and critically, where.

B

We've taken enforcement, action.

B

I, do think. One of the quiet successes of last year was the fact that not only did.

B

We do more inspections, but our enforcement activity, increased,.

B

It was always a risk going back to the risk register that what we'd end up doing.

B

Was trade and enforcement activity just to get the work done, that we took an.

B

Optimistic view- and this figure gives us some comfort- that we didn't do that.

B

Our enforcement activity went up during that year.

B

Registration has seen an increase and a spike in activities and I think slide. 12.

B

Pulls out what some of the trends that they've been experiencing, registration.

B

Can often get forgotten as we talk about inspection and the progress, but.

B

Nevertheless, is a hugely important part of our work and as we move forward.

B

With these increased powers that we've got to change the notice of proposals.

B

Will become increasingly important, it strikes me moving forward.

B

And then slide 14, 15, 16 are really about the internal workings of CQC.

B

Rather than our external work about our HR activity- and there is some good.

B

Statistics in here for the end of the year, just in terms of recruitment activity, but.

B

Also, our retention activity,, the number of people that stayed with us and turnover.

B

And sickness levels, sickness rates,, which I think continue to be good.

B

Indicators of the commitment to CQC staff to get the job done and to stay with.

B

Us, so I won't say anymore than that David,. That I think presents the final.

B

Report on 13/14, the figures in this report once they're audited, that's a.

B

Delegation I asked for in the end of my report, will actually find their way into the.

B

Annual report, which is on a trajectory to end up being presented to Parliament in.

B

July and that will help us discharge our responsibilities to produce the annual report.

A

Thanks. >> Thanks, Paul did you want to add anything?

A

C

≫≫ Just to say that just looking at slide, 3, scorecard summary,, just actually we.

C

Have delivered on what we said we would deliver,. So that's very impressive.

C

During an extremely -- time of extreme change,, so I think that's really good.

C

A specific question I had was, enforcement is up by 50 percent,.

C

I just wondered what the reasons were for that?.

C

Because, it's quite a big jump, I just wondered if there were other factors.

C

Other than people working really hard and making sure they didn't take their.

C

Eye off the ball.

A

≫≫ It's interesting, it is up by 50 percent, but it's still 5 percent of the inspections.

A

Which is still quite low, I would have thought.

A

Is there a reason why it's gone up from one year to the other?.

B

≫≫ I think we pressed on it, I. Think Andrea's report talked about the use of.

B

Fines in relation to the absence of registered managers, I think the Board.

B

Has challenged the executive over about an 18-month period about? What are you.

B

Doing,, how are you getting this up,? So there is a sense that sitting down and.

B

Planning how we do that is making some results.

B

I think there's also;. The organisation, paradoxically, has felt more settled,.

B

People have actually got on and said, actually we are going to challenge.

B

Unacceptable care and I think people felt supported to challenge unacceptable.

B

Care, so, in addition to the registered manager's, activity, I just think it.

B

Represents a greater confidence in staff and managers and I think.

B

Rebecca's team, as well in legal, in taking more.

B

I think David's got absolutely the challenge,, but it's stuck at about.

B

5 percent,, and is that enough, given the levels of poor, care?.

B

And I think the slide which we've looked at on numerous occasions,, which is.

B

Slide 7,, which is the amount of care, which has been assessed using the old.

B

Methodology as being non-compliant for more than 6 months, 9 months and.

B

12 months, really does give I think some focus to whether that 5 percent is the.

B

Right figure,, this is rather saying we actually probably should be doing more.

B

Than we've been doing, and that I think is a challenge for this next period.

B

Certainly I think on adult social care and the work Steve's,. Sorry on hospitals and.

B

Primary medical services, with the "failure regimes" we've got clearer.

B

About what some of the timescales will be before, we will take action,.

B

And how long people are going to be given to start turning around services?.

B

And I think there's a similar conversation that we need to begin having about.

B

What's a reasonable period of time for these services to turn around and when.

B

Should we begin to see evidence and I think we need to extend that into adult social care as well. So there's a big piece of work to do around enforcement,, but I, don't think.

B

There's one simple single reason: why that's gone up? 50 percent I think it's.

B

About a combination.

A

≫≫ Rebecca, how do you feel it's going on the enforcement side?.

F

≫≫ I think David's right that there has been an increase in confidence in taking.

F

Enforcement activity, but I think there's a lot more that we can do to embed the.

F

Skills of those already at the top end to make it uniform, because what we don't.

F

Have is consistency.

F

I think getting our enforcement policy right, when we have the.

F

New framework, is going to be really important,, because that will explain.

F

More publicly how we come to decisions that we do on enforcement and I.

F

Wouldn't underestimate the scale of the challenge actually to get to the point.

F

Where every inspector has got all the skills they need to get the evidence,.

F

To get that first inspection, absolutely right, so then we can follow it. Through.

F

We, don't have that uniformly now.

F

But that plays into what David was saying about the training that we need to.

F

Do between now and October, to hit the ground running with the new framework.

D

≫≫ At the moment there are structures around 20, 25% non-compliance, but the.

D

Majority of that results in compliance action and the vast majority of what we.

D

Don't do on the compliance action is a warning notice,. That's almost the top of.

D

What we do,, as you can see on the left-hand side of page 11, there are an.

D

Extremely small number of cases where we go beyond warning.

D

Now as the regulations change and as we look to our new enforcement policy,.

D

One of the things we're looking at is currently we have an escalation ladder.

D

It's called,, so you step up, but linking to Kay's point at the beginning of the board.

D

Meeting,, if there are things that are just happening, that should not happen and.

D

We had the fundamental standards to prove or set the basis in law. Then we.

D

Need to be looking at,, we should just go to the most appropriate action straight.

D

Away,, so one thing we might see in future reports is more direct to prosecutions.

J

≫≫ It's really a question of clarification.

J

On page 4 under the heading, second section of page 4 on the right, it says;.

J

4,679 locations cancelled their registration in the year,. This suggests to.

J

Me but, I, don't know how to think about this, that there is a very large amount of.

J

Churn happening,, so I just wondered what was causing that and whether.

J

These figures had spiked or what happens every year and does it literally.

J

Mean that nearly 5,000 locations actually close every year or are they.

J

Transferred or what happens to them?.

J

And it also on page 12, which has got the number of.

J

Registrations, I was also surprised by this figure, that CQC received 48,472.

J

Registration applications that also felt like a very high number, and I'm, not quite.

J

Sure, Eileen,, who the right person to ask about these are,, but both these.

J

Numbers struck me as being numbers that were worth thinking about and.

J

Understanding what was driving them.

K

≫≫ I think Andrea will come in on the specifics of the numbers,, but I think it's.

K

Really well worth noting, because it's important that the sheer upswing in the.

K

Amount of activity around registration and people who are connecting and.

K

Contacting with us is having huge impact on our front door,, which is the NCSC in.

K

Newcastle and they are doing sterling work in dealing with this upswing in contact.

K

But, we need to look carefully at it because it seems to be a trend that we.

K

Are going to have to live, with, Andrea I, don't know,! You lead on registration,.

K

If you want to pick up on that.

I

≫≫ Yes thank you,, one of the things,. Yes, there is churn and sadly I, don't.

I

Know what the historical context is, so I'm sure we can come back on that Michael.

I

But in terms of the numbers of applications we get, what's not shown.

I

Here and I can't remember the specific percentage, but there's a very high.

I

Percentage of applications that people make that we reject,.

I

For a variety of different, reasons.

I

So, one of the things we're looking at in the registration, design and delivery.

I

Board is how can we take our process and the information that we're providing.

I

To people further back and actually do some,, if you like preventative work,.

I

Around being much, much clearer about the information, that's on our website.

I

That we share with people that basically says if you can't answer these basic.

I

Questions,, if you can't commit to these legally binding requirements, etcetera,.

I

Etcetera,, then don't even pass go because actually you're not going to make the grade.

I

Because, what happens at the moment is that people put in pretty speculative.

I

Applications which we have to treat properly and reject,, but that's a very.

I

Inefficient and ineffective use of our time.

I

So, one of the things that I'd really like us to be able to do is to think about.

I

Ourselves as providing much better information to people who are thinking.

I

About making applications or changing their registration so that we can be more.

I

Efficient and effective,, but also so that people can make much better informed.

I

Decisions about what they're applying to do,, so there is quite a bit of work to be done on that.

D

≫≫ On Andrea's point, a lot of the rejections and the high rejection rate is.

D

Because there's been a manual process,, you submit a Word document,.

D

What we have seen as we've moved to online services, which we've done for.

D

Primary medical services to start with and are rolling out to all the other services,. There is something like 50 percent drop in the rejection rate when.

D

It's done online, because you can prompt people to say you have not filled.

D

In this box- and it's probably because they have forgotten it,, whereas if it's.

D

Sent in as a completed form, you have to reject if they missed a box,.

D

That's good for us, but also for providers.

D

On your point about the total number,: that's total number of applications and a.

D

Lot of those aren't new providers or even new locations, they will be an existing.

D

Location, looking to register a new activity,, so that's probably a large.

D

Proportion of the difference between the churned figure,, as you described, it,.

D

And the new application figure and again the churned figures wouldn't necessarily.

D

Be about the asset,, the location no longer being there, any shift from one.

D

Provider owning it to another provider owning it,, a continuity of care would still.

D

Require a new application and a deregistration of the old one.

A

≫≫ Can, we get the last question Kay?.

C

≫≫ It's slide 13 and it's the SOAD requests for ECT.

C

And in the last quarter, it's gone down to 38 percent, which is quite a significant.

C

Drop, I know there are on-going problems with recruiting SOADs and.

C

That Paul Lelliott is looking at that,, that's quite a significant drop,. Essentially it.

C

Means very ill, people are waiting for ECT or more likely are given it under.

C

Emergency powers,, so I just wondered why there's been such a drop and what.

C

Are we doing to at least get it back up to where it was?.

E

≫≫ Can I take that one away and come back to you?.

A

≫≫ Right, I think unless there is any other questions, we should probably.

A

Move to the end of the public meeting, any questions from the floor?.

A

Sorry one more item.

A

David you're going to do that.

B

≫≫ I'll do this quickly, taking the encouragement, so in presenting the.

B

Fourth quarter report for 13/14, I signalled that there's been work.

B

Undertaken to redesign the reporting process and what you've got at item,.

B

The last item on the agenda, David, is a new performance scorecard.

B

Paul's team, developed, this, I, know there've been a number of discussions.

B

Between both executive members of the Board and non-executive members.

B

Of the Board, which have been very helpful,, the annex to the report is a.

B

Created annex,, this isn't real data.

B

But, it's showing you how we would intend to present performance and.

B

Finance information for CQC for the year 14/15,, so the first of these you'll be.

B

Getting is in July, where you'll get April, May, June, the first quarter of both.

B

Financial performance and operational performance for this current year.

B

I, don't intend to go through it slide by slide,, but what we're trying to do is.

B

Actually keep what was good from the previous reporting system, I think where.

B

There's been resistance to progress and change, the slide that we looked at,.

B

On slide, 7 on the last report is in here,, but it's now broken down to represent.

B

The directorates at each chief inspector leads and you'll get greater granularity.

B

And Michael I hope some of the questions you asked on. What's behind.

B

Some of those numbers,, this presentation will make that more accessible.

B

So, David,, rather than go through and try and present it, I hope. This really.

B

Meets the Board's requirements for a more granular and more accessible.

B

Performance and finance report that represents and reflects how we're.

B

Organised as an organisation and would allow that greater scrutiny from the.

B

Board, and a greater transparency for members of the public that stakeholders.

B

And other key people that are interested in this information and want to access it and interrogate it.

B

I'll leave it there.

B

≫≫ How: do you feel about that, generally speaking,? Do people feel it's an.

A

Improvement on what we've had in the past,, yeah?

A

I. Think it's -- Camilla. Are you happy with it?.

A

It's difficult to, until we've actually got real numbers in here. It's quite difficult to really ...

A

But, it feels much better to me.

A

So. Can we try -- Mike? You wanted to come in.

E

≫≫ Can I just enter a caveat,, which is when we're looking at trends in good.

E

And outstanding ratings,, clearly in the hospital sector, where we have been.

E

Selecting high risk Trusts and we're not just doing a random sample each.

E

Quarter,, we may get some funny trends where things will suddenly look better or.

E

Worse, depending on which groups we're selecting.

E

A

Good, thanks very much.

A

Eileen, thanks for getting all the work pulled together on this as well and Paul..

K

≫≫ It was very much a team effort led by Mark Edmonds I have to say,.

K

So we're very grateful to him for that.

K

>> Okay good, thanks very much.

A

Questions from the floor.

L

≫≫ David Hooper, as usual. My questions are mainly towards Andrea,.

L

Under the old regime in CQC, there were quite a lot of instances where the CQC.

L

Gave providers a clean bill of health,, then somebody put in a camera and a.

L

Very different story was told,, that's gone down,, but it hasn't disappeared and the.

L

Old Deanery is an example of where that sort of thing happens,.

L

I'm sure every single person around this table would want to reduce that sort of.

L

Thing to the absolute minimum.

L

For it you need, the trouble is, it really happens because you can't get into the.

L

Corners,, you can't see, everything, cameras do help with that and they are.

L

Also objective,, if they weren't objective, it wouldn't have been possible for 7 people.

L

To be dismissed in open, house.

L

So I do hope, that, I think this is the reason why in the round table, nobody.

L

Actually said, cameras shouldn't happen at all,, though definite restrictions on it,.

L

So if you were to actually have the word camera a bit more in the mitigating.

L

Action column of the risk register I think you might get a bit more green in the red column.

L

Secondly, one way you can help cameras, I tried to put a camera in a.

L

Home once, I came to grief because I couldn't work. The wretched thing at all,.

L

Secondly, I wouldn't have known where to put it, CQC can do a lot to help with.

L

That,, particularly the CQC could set itself up as being the place,, the first port of.

L

Call when you've got some footage, rather than going to the Daily Mail,.

L

Panorama or anywhere else,, in other words, to be not just responsive, but encouraging.

L

Then going to back to what Steve was saying if I was a commissioner I would.

L

Much rather be inspected through the lens of my providers than to have an.

L

Actual visit from the CQC.

L

I still like to see CQC inspecting commissioners and, in particular local authorities.,.

A

≫≫ Thanks David, Andrea. Do you want to respond?.

I

≫≫ Yes, thank you., I. Think the issue about cameras we discussed and we will come out with a.

I

Position statement after the consultation has ended, and it was very helpful to.

I

Have your points of view at the round table as well David,, so thank you very.

I

Much for doing that. I think that the point that you're making that CQC could do a lot in terms of.

I

Being the first port of call with people not taking information to the press or the.

I

Tv, in one of the circumstances that was in the Panorama programme, which.

I

Was Open House,? Actually, the family took the footage to the management of.

I

The home directly in 2012, when it happened,, they responded very quickly,.

I

They involved us and the consequences happened,. It was awful footage as you.

I

Quite rightly say,, but it did actually generate the immediate response that.

I

Was required, as opposed to undercover reporters reporting on things and waiting.

I

Several months before they share it,, which doesn't allow us take that immediate action.

I

So I think encouraging people to go either to the management of the service.

I

Or indeed, to us is an important thing in terms of us being able to respond and to.

I

Respond in a timely fashion,, which I think is really important.

A

≫≫ My name's Ian Stevens, I'm at King's College, looking at corporate governance.

A

I have a question for Professor Mike,, the meeting discussed domain level and.

A

Service level, scrutiny of Trusts, I: wonder if you could comment on the.

A

Governance and control level scrutiny when you do your assessments of.

G

Trusts,, because there is a layer of governance that is provided,, for instance,.

A

The elected governors,, which I think would have quite a serious bearing on.

H

The behaviour of those boards?.

E

≫≫ In all our inspections. We look at,, particularly the governance of quality.

E

And safety,, as that is what we're really looking at.

E

We will normally interview chair and chief executive,, but also the.

E

Non-Executive directors, and particularly non-executive directors who are.

E

Chairing quality and safety committees, whatever they may be, called in different Trusts.

E

In Foundation Trusts, where there are governors,, we tend to meet with the.

E

Governors as a group to get their views on quality and safety and to see how.

E

Closely, they are engaged with the Trust and I have to say. We have observed.

E

Quite a variation in that from governors who are very highly engaged and have a.

E

Very close idea of what is going on and are obviously working closely, but.

E

Separately from the board, and I've been to one place where they said, we are not.

E

Mini NEDs and they knew that was their role,, so I think we do look at all of.

E

That, and of course, we also look at written reports of governance, meetings,.

E

Particularly related to quality, as we go, through.

F

≫≫ Thank you chair, Robin Pike, a couple: if I may quickly, going back to the.

F

Care Bill, which was an early part of the meeting and the regulations, which are.

F

Under discussion for implementation on October 1st, from a patient perspective,.

F

What do you think the impact will be in a particular circumstance, such as a never event?.

F

At Watford hospital. There have been several never events, recently,.

F

Including a wrong site surgery.

F

Would that constitute a threshold for prosecution?.

E

≫≫ It would depend on the circumstances, I think that's the first thing to say, in general no.

E

But. We certainly always look at never events and we use them as one of our.

E

Assessments of the past safety of a Trust over the previous 12 months,.

E

But we're also looking at a whole range of things about safety,. Was it safe in the.

E

Past, is it safe now,? Is it likely to be safe in the future, which, for example, we can.

E

Look at by have they got an open learning culture,. Are they being.

E

Encouraged to report incidents, minor incidents as well as major incidents,.

E

So that will be one factor.

E

Clearly if there had been a number of never events and they had all been.

E

Occurring in the same part of the hospital.

E

So, supposing it's not just in surgery,, which is were most never events, occur,.

E

But it's within one branch of surgery,. We look very carefully at that and want to.

E

Look at the governance of that,: are they using the WHO surgical, check-list.

E

Properly and so we would look at a whole range of different factors before.

E

Making up our minds,, but if we feel there has certainly been willful.

E

Negligence and neglect,, then we can take action.

B

≫≫ Can I just add to that?.

B

Mike's absolutely right. One of the regulations is called safe care in treatment,. That's where it would.

B

Apply,, but also remember, the duty of candor is about the reporting of those.

B

Openly and honestly, and that will be subject to a regulation.

B

And, although it's not in this report,, but we flagged it separately,, there's a.

B

Separate set of responsibilities for how we work with health and safety.

B

Executive, which also pick up on the issues about safety,, so I, think your.

B

Question prompts me to think that we need to be really clear in our guidance.

B

About how we see that applying.

B

Never events, by definition, are never events, but never events do happen,.

B

The issue isn't: do they happen, it's what happens when they happen and how.

B

Does somebody respond to them, I think is the key issue.

B

And. That's why I think Mike's answer was about. They won't apply in all.

B

Circumstances, but there may be some where people are willful and they will apply.

B

I made a distinction earlier about civil and criminal prosecutions,. The regulation.

B

Around safe care and treatment is potentially a criminal prosecution.

F

≫≫ Thank you and very briefly, if I may,, a question about pharmacies.

F

Pharmacies in the community are I think increasingly delivering some medical.

F

Services,, which are moving from general practice into community pharmacies,,.

F

Is there any inspection by any agency of those pharmacies and within hospitals,.

F

The pharmacies from a patient perspective can lead to poor.

F

Experiences,, both patients who are waiting to be discharged from a hospital.

F

And to obtain their medication before they can leave, and also for outpatients.

F

Who have been prescribed medication and have to go through the hospital pharmacy.

F

Are either or both inspected?.

E

≫≫ The issue of pharmacy and particularly medicines being available.

E

Before discharge is something we do routinely look at, most frequently, it's.

E

Within our medical care core service- and we would look at that within the.

E

Responsive domain from medical care, and we do, quite often,, observe that.

E

People are waiting for several hours in the discharge lounge, while they are just.

E

To get their medication, this by the way also comes through in the CQC.

E

Inpatient survey,, where there is a specific question on that.

E

So we can corroborate between the survey and what we hear on inspection,.

E

And it is quite frequently a cause for us saying that the responsive domain of.

E

Medicine requires improvement.

B

≫≫ On community pharmacists, we don't do that,. There is a separate body that looks at community pharmacists and that's not our responsibility.

A

≫≫ Okay,, thank you very much..

F

≫≫ Very, very briefly, on your question about cameras, Andrea, you said you.

F

Were going to publish a position statement, is that going to come to the Board?.

F

Is, that a sort of policy, is it going to come to the Board before?.

I

≫≫ Yes, it will be as a consequence of the consultation that we have a done on.

I

The provider handbooks, I'm not going to make it up by myself!.

A

≫≫ Right thanks very much. Subtitles by Premier Captioning &, Realtime, Ltd. www.pcr.ie.