Care Quality Commission Board meetings, 18 Jun 2014

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From YouTube: CQC Board Meeting 18 June 2014

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Agenda for the meeting of the Care Quality Commission Board held on Wednesday, 18 June 2014:

1. Apologies and declarations of interest 0:01

2. Minutes of the meeting held on 21 May 2014 0:39

3. Matters arising and action log 0:43

4. Chief Executive's report 1:46

5. Updates from CQC Chief Inspectors 45:29

6. Future plans for strengthening our Mental Health Act duties 1:04:52

7. Culture and values 1:21:58

8. Requests from providers to review ratings 2:01:31

9. Annual report from the Audit and Corporate Governance Committee 2:14:36

10. Board forward plan 2:28:52

11. Any other business 2:28:52

12. Questions from the floor 2:28:57

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

A

≫≫ Okay, can we start please?

A

Firstly welcome to Robert Francis,. Actually it was Sir Robert Francis on that.

A

Thing- and it was premature, so it was taken off and it hasn't been put back. So.

A

(Laughter) And Paul Roux at the end who's joining us as chairman of the audit committee.

A

So welcome to both,. There are apologies from Steve, Field and Michael Myer.

A

I think Steve is lecturing in Harvard at the moment, sounds very erudite.

A

And, if anyone's got any declarations of the interest, please speak now.

A

No, thank you. Minutes,. Everyone happy with the minutes?.

A

The only matter arising was that Three Lives event on Winterbourne View.

A

Which is going to be published later on today, Louis I think you're happy with.

A

What you saw on that.

B

≫≫ It's a very important step, because the event that we held was really quite.

B

Emotive and the issue there was whether or not the system would.

B

Respond to these events properly,, it was one thing to have a plan and.

B

Government concordat. As, we were talking about last night. Some of the signs have not been good.

B

Until now,, but there's a sense that the programme of work that followed.

B

Winterbourne View, the programme on learning disability care,, particularly for.

B

People with complex needs, that that will now be properly addressed.

B

Now, there's quite a bit of scepticism out there. Whether Winterbourne View will.

B

Really feed into the system, whether these patients matter enough to.

B

The NHS and social care system for it to change the way it works to.

B

Accommodate them.

A

≫≫ Okay, thank you. David, your report, please.

C

≫≫ Thanks David. Good morning, everybody.

C

So I suppose the biggest issue that my senior colleagues and I have been.

C

Dealing with over the past couple of months in truth, is the issue around.

C

Appointments, recruitments and workloads.

C

Paragraph one of this report I've attempted to set out some of the issues.

C

That have come through communication across the organisation as a result of.

C

The recruitment exercise and the implications that this has got for workload.

C

We're endeavouring this year to recruit an additional 500 people,. This is a.

C

Mixture of inspectors, inspector managers and analysts working in the.

C

Strategy and intelligence, directorate.

C

There is a recruitment process that is under way.

C

That will begin to --. Appointments are currently being made from that.

C

Recruitment process of both inspectors and inspection managers, that process.

C

Completes around the middle of July in this current wave and appointments.

C

And people will start arriving on their contracts from later in the summer, but.

C

The process of their arrival will not be completed until September/October time.

C

We're offering all new starters 30 days, training through the academy in terms of.

C

The knowledge and the skills that they will require to undertake the job of.

C

Inspector and inspection, manager., The, training's planned,, the people to be trained have not yet arrived and, as I say,.

C

Won't arrive,, so new staff will not become productive until we calculate.

C

October and I think we've set this out in the report.

C

The consequence of that is that the volume of work that we need to.

C

Undertake as an organisation and the additionality of people grappling with.

C

New methodologies, new ways of working, means that a number of our.

C

Staff feel under some considerable pressure in relation to it, and there have.

C

Been stories of some people who have become stressed and anxious and.

C

Upset as a consequence of that pressure.

C

That resulted in a note that was -- to the trade unions -- from the trade unions to.

C

Our health and safety committee, where colleagues had expressed some.

C

Concern about the intensity of the inspection programme, around hospitals.

C

That Mike was dealing with the trade unions, being sent to the health service journal.

C

Our response to that was,, okay, this isn't something that's secret,. We've been.

C

Talking about this across the organisation,, there was nothing new in that story, and our response to that to the health service journal was to.

C

Acknowledge it was an issue and get on with it in a sense.

C

And actually take significantly the fact that people have been expressing their.

C

Concerns about workload and get on and deal with, it.

C

What we've agreed across the executive team. We'll do is we'll begin to target.

C

Those areas where there are particularly pockets of vacancies.

C

One of areas is in mental health services, where those teams are.

C

Seriously, under their capacity that we planned them to be, and there will be a.

C

Dedicated recruitment programme around mental health,, which is designed.

C

To address that and we'll be looking not just at recruiting permanent employees,.

C

But secondments of people who are currently in the field.

C

We also know that some teams are pretty much fully staffed, they've got one.

C

Manager and eight inspectors,, but then there are other places where we've got.

C

One manager and two inspectors and therefore they're six down and carrying.

C

Those workloads, so we'll target those areas specifically to make a.

C

Difference to those areas.

C

We're also looking at the commitments that we've made during the year,.

C

I.E. the work programme.

C

So, as well as trying to speed and accelerate the number of staff coming.

C

In, we're not going to accelerate the training,. We think this needs to be done.

C

Properly,, we've previously be criticised on training and we're going to hold the line on the 30 days, training and not rush that through,. But we're also looking.

C

At the work that we're expecting people to undertake.

C

So I think chief inspectors are working with their senior teams, now they're in.

C

Place, to look at what offers we can make in relation to focusing on our.

C

Priority areas of high risk and those areas of least risk, they'll receive less.

C

Priority for inspection during this coming year.

C

So by the end of the year, we can get into a better balance between the.

C

Resource we've got available and the work that is coming through the door.

C

We've tried to set that out to staff in weekly communications.

C

Colleagues will know that I write out to staff every Friday,. This issue about.

C

The balance between workloads and recruitments and also the.

C

Disappointment that some of our staff feel at not being selected for.

C

Promotional posts in particular, and the fact that they've not received feedback.

C

From the recruitment agency, has led to me having more emails on this one.

C

Particular subject than any other subject since I started the job, that includes.

C

People's protection and salaries ending and all the issues about specialisation.

C

When we began this journey to where we are today.

C

And I think that gives a signal really of the issues.

C

Later on in this agenda, we'll consider the work on the staff survey and what.

C

That tells us, and I think it's fair to say, and I've got a line in here, that morale.

C

Has suffered as a consequence of these issues.

C

I, don't think it's inevitable that when you go through a change programme that morale has got to suffer,, but the truth is that morale has suffered here and I.

C

Think what I'm trying to do in this update is acknowledge that we've listened to.

C

And heard the messages from staff that are disappointed, under pressure,.

C

Et cetera and that we are taking some action to address those issues.

C

I was concerned about the messages coming back about the recruitment.

C

Process, had we set the bar too high,. Some of our staff felt it's unfair,.

C

The internal staff have not had preferential treatment for appointments,.

C

So I personally went through every test, every exercise,. Every guidance note.

C

That we've designed around this, and I think this is an industry standard.

C

Assessment centre for any appointment in either the public or private sector.

C

It's consistent with anything I've personally done or any other job I've.

C

Previous overseen, as well.

C

I, think it's also right that any promotional jobs we've got are offered.

C

Simultaneously, internally and externally, and there's no preferential.

C

Treatment for internal candidates in relation to this.

C

And, that's not to devalue internal candidates,, which is how some people.

C

Have experienced it, but to say we're setting a bar for the standard of.

C

Applicants we want in CQC and the standard of employees that we.

C

Want- and my sense is, we need to hold a line on that, whilst also offering out some.

C

Hope to staff who have not succeeded on this particular opportunity that they.

C

Will get another chance to apply for promotional posts in the future.

C

These are tough messages,, hard messages,, but my view is: we need to.

C

Hold the line on what we've started and continue with that.

C

Second issue that -- sorry just to finish, I'll bring to the July meeting the outcome.

C

Of the chief inspectors' reviews and NET's reviews of those three plans.

C

About how we'll prioritise work and balance of resource and we'll report that.

C

To the board meeting in July, David.

C

Second item is the gateway review.

C

Just to note that we had an initial gateway review a few months ago, which.

C

Was a beginning of our transformation programme,? The audit committee have.

C

Overseen this programme and I think John Harwood, in his last report,.

C

When he was the chair of the audit, committee, made a number of recommendations to the board about changes. We need to make.

C

A further gateway review will start on the 14th of July, will last for three days and.

C

Allows some further external scrutiny and challenge of the transformation.

C

Programme and again we'll report that to subsequent meetings of the board, when that's completed.

C

It's likely to be the September board meeting before we report that to you.

C

The third item is Orchid View report.

C

Colleagues will know we published this report and I don't want to cut across.

C

What Andrea's going to go, say and she's got more details of the report and the.

C

Issues that we've taken, and the action we've taken, in her report,.

C

Which is one of the next agenda? Items.

C

My purpose, including it in this report this morning, is not to steal, Andrea's, thunder.

C

But just to point out,, it needs to be in the chief exec's report because it was a.

C

Significant issue and therefore I'm trying to signal this was an important issue, but.

C

The true importance of this, was I think this report now sets a standard for how.

C

We as an organisation, need to deal with concerns and complaints that are raised.

C

And, where we've got something wrong, or we feel we've made a mistake. We.

C

Should carry out a root cause analysis, that should be captured in a report and.

C

That report should come both to the executive team and then to this board.

C

Which identifies what happened,, what the learning is, and what we intend to do, differently.

C

That's the point I want to pull out in this, and maybe the words in the report kind.

C

Of mask that really, but it's that important principle of demonstrating our approach to openness.

C

Camilla, I, don't know whether this is an invitation, I understand there might be.

C

Some things that you want to raise in this spirit of how do we raise issues around openness.

C

So I'm quite happy to pause at this point. If you want to use this opportunity.

C

I was filibustering as long as I can,, so that you could get here,.

C

I'd have run out of things to say... >> Or. You can leave it... >> The gateway, review.

A

≫≫ Do, you want to come back... >>, I'm happy, should I do that. Now? >> The context was on Orchid View.

D

A

≫≫ David was saying one of the key things is for us to be open when things.

A

Have gone wrong, that we're completely open about it, I thought that was maybe.

A

The context you might want to mention your two issues.

A

D

≫≫ One of the most useful things that I've found, since joining the board,.

D

Has been to try and look at things from the bottom up.

D

And I'm, quite lucky that a lot of people write to me with their own concerns,.

D

There are other people around the table that have had the same experience, I find that really useful,, because a lot of what we discuss here is high level,, very.

D

Important,, but it's quite high level and I think it's very useful to remind ourselves.

D

Sometimes of how we deal or don't deal with the people at the bottom,.

D

If you know what I mean, so I've had quite a lot of cases, I've tried to follow.

D

Through,, where people have come to complain, and try to see how did we deal.

D

With them as an organisation and what resulted.

D

And, there were just two that David thought might be useful to talk through very briefly, now.

D

I chose one from social care and one from the NHS,, because I thought that would be even-handed, the social care. One is much, much simpler.

D

So, if I just really briefly and I'll, do it anonymously, because that's probably.

D

Fairer to the people who wrote in.

D

On social care, the CQC did an inspection last May into a care home.

D

In Rochdale, we didn't inspect medication because we didn't have any.

D

Reasons to suspect there was a problem.

D

In July of that year a man was given a massive dose of the wrong drug and he died, and his son wrote to me because he felt 11 months since that happened.

D

The issues haven't necessarily been resolved.

D

A lot of people who write to us are very reasonable,, articulate people and they.

D

Actually, don't want to make a big fuss,; they just want things to be put right and he's. Certainly in that category.

D

One of the things this particular case, -- I- think it's probably been resolved now, but.

D

One of the things it slightly reminded me of was some the child protection cases,.

D

That sometimes nobody takes responsibility and things go around and around.

D

One of the points that the son of this man made to me,, this is kind of a.

D

Situation where there are three different organisations and nobody's, as he put it,.

D

Put their foot on the throat of the home,, which is a little unfair, but you get the point.

D

So the man died in July, in December. There was a case conference by the.

D

Borough Council, to which CQC was not invited.

D

In February CQC carried out an inspection and carried out a further.

D

Inspection three weeks, later.

D

It did so apparently unaware that the coroner had issued a Regulation 28.

D

Report saying that there was still a problem at the home, and we still.

D

Haven't got to the bottom of why.. We did receive the letter, but we don't quite know why it didn't escalate.

D

In that inspection we found that the home was still not compliant with.

D

Medication and various other things as well.

D

One of the things the son said to me is that the inspection,, the things that we found in that inspection, were exactly the same things that he, from a personal.

D

Perspective, thought were wrong., This was quite a long time after the original incident.

D

We did in fact do another inspection on Tuesday and we were expecting the.

D

Home at that point to be compliant because they had put an action plan in place.

D

I think the son feels that probably things will be resolved.

D

There's two things that struck me about that case, and they're similar to the next one,. One is lack of sense of urgency in some of our response and the other one.

D

Was that nobody could quite grasp who was responsible for what.

D

And there was an awful lot of,. The CCG was very good,. The coroner was upset.

D

That we didn't contact her, so on and so forth, so bits of process there.

D

The second case is slightly more complicated,. It's an NHS case,.

D

Which poor David, our chairman, has got very involved. In.

D

One thing,, as we all know, happens,, that if someone doesn't get the right.

D

Response, the first time, this particular person, became a serial letter, writer.

D

At that point, probably the organisation may have thought, we're, not sure this.

D

Person is serious,, in fact they were serious, but they became more and more.

D

Frustrated with the system.

D

This man's mother died,, sadly, he believes, of failures in her original.

D

Treatment at a social enterprise, which led to her being admitted to the Great.

D

Western Hospital last year and he raised a number of different issues,.

D

One was that he said that her medical records were inadequate,.

D

One was he said: he had made a series of complaints that the hospital hadn't.

D

Responded to at all, he wrote five letters to the executive of Great Western.

D

Which were not responded to, and he also slightly complicated the issue by.

D

Saying he had another friend who had died of C-Diff at the hospital.

D

So, of course, the letter which arrived -- several letters arrived,, but quite a jumble.

D

Of complaints, and this organisation dealt with them, I understand by trying to.

D

Separate bits out and sending them out to different people.

D

And, essentially, what we failed to do was give him any response that was specific.

D

So to cut an extremely long story: short, as David knows, and David wrote.

D

Some of these responses, they got better and better, as time went on.

D

We essentially gave him general responses,, where we should have given.

D

Specifics,, every single time, and when I intervened- and this was seven months.

D

After he originally came to me, and I must say every single time that I have.

D

Contacted the organisation,, the organisation has been brilliant in responding to me and trying to get to the bottom of these things,.

D

But the organisation's first response to me was to create a suggested response,.

D

Which included the sort of phrase that suggested that CQC has taken your concerns very seriously.

D

I wasn't going to sign that letter because it obviously wasn't true.

D

So, the organisation's first response was to say, -- and to offer him a meeting.

D

In both these two cases, our first response was to offer a meeting which is right,. It's an open and transparent approach,, but without having dug down to get the full facts.

D

Now by the time the GWH case had reached David's desk, by the time I got.

D

Involved the number of people in this organisation that got involved was huge,.

D

The amount of time and energy it took was enormous.

D

I then went through all the paperwork,, all of his letters and all our letters,, which.

D

Were very difficult to collate, because this organisation did not actually have,.

D

For quite a while,, all of that to hand. It, clearly wasn't in one filing cabinet and lots of people helped, but it wasn't to hand.

D

I pinpointed the four questions, I thought he was asking and none of.

D

Those questions --, we hadn't done that exercise.

D

I then looked at what we had done about the four questions, and I'm afraid to say.

D

In each case, -- we'd sent a lot of paper around the system, but we hadn't.

D

Necessarily got traction with the questions.

D

And. What we hadn't done, critically, was to tell Mike's team who were inspecting.

D

The hospital about the issues.

D

Mike would have made a judgment about how seriously to take those issues.

D

But he wasn't informed.

D

It doesn't quite gel with our sense of intelligence, wanting to gather intelligence.

D

So I mean I, don't want to sort of prolong this because obviously one could talk.

D

About it forever, but there's a couple of things it raises and I don't want to say.

D

They're typical either,, but I do think that it raises just a couple of issues about the way we respond.

D

One is tone,, were it not so tragic? It would almost be hilarious that the letter.

D

That the second man received from NHS England said that it couldn't deal with his.

D

Complaint because it only dealt with primary care, which was just astonishing.

D

So, some of the letters that are generally in the system are surprising.

D

We have, I think, we've got --, we've got to change our language.

D

We can't obviously give individual people always an absolute resolution of their.

D

Issue but I think we need to get slightly better at connecting with what they actually want.

D

Most of these people want to know that what happened to their relative is not.

D

Going to happen again- and we tend to give bland reassurance- which is not convincing.

D

I also think sometimes; David you'll know better than I, I. Don't know whether.

D

We need to change our process,, but we need to sometimes get a little bit better.

D

About deciding where, in the system, this has traction.

D

So on this guy, I mean one of his complaints about the social enterprise.

D

Went to NCSC,, it went to the safeguarding team,, it went to the.

D

Inspector,, which was completely the right process.

D

The inspector, didn't do anything about it and has left no note about what they did about it.

D

So that should have, at some point, triggered alarm bells.

D

It wasn't that we did the wrong thing,, it's just at some point. It disappeared.

D

We need to be, I think we also maybe need to deal with this issue that Paul's.

D

Raised before, which is whether or not we investigate individual complaints.

D

So, of course, we say we don't investigate individual complaints,.

D

It's a very tricky line, because, of course, we need the intelligence from individual.

D

Complaints to feed into our inspection process and we can't take an individual.

D

Complaint to its end conclusion, and we do sometimes say to people you need to.

D

Go to the ombudsman,, but it seems to me from looking at our correspondence.

D

That we're very quick to tell people to go to the ombudsman,. It's one of our standard paragraphs and people, misunderstand that and they think --.

D

In this case, probably correctly, you're not doing anything about it.

D

So I wonder if there's a bit of a case for going back over that.

D

That's all I really want to say here, because there are three things at stake,.

D

One is our reputation, one is the genuine issue of intelligence, gathering,.

D

That, if the intelligence isn't getting to Mike's team, it doesn't help, and he was.

D

Actually doing a cleanliness inspection at the time when this guy was complaining about infection. Control. And, the other one is just our own time,. It's not efficient.

D

So I think being slightly smarter about this would probably save us time and money.

D

Does that make sense?.

A

≫≫ Yeah, I wanted Camilla to raise it at a public meeting because it does bring.

A

Home and actually I have to say when I get complaints, difficult complaints and.

A

Three and four letters, your heart sort of sinks,, but it shouldn't sink because.

A

For that person writing in,. The failure of the system is 100 percent.

A

Camilla,, thanks for that and we'll take that on board.

C

≫≫ I think this is really been the Health Select Committee. Yesterday, all over again.

C

And part of our narrative, I think.

C

So under Michael,, the committee that Michael chairs,, we are reviewing our.

C

Internal processes for complaints, so I think you've used those cases really.

C

Well, Camilla, to fillet out some of the issues around tone, the connection with.

C

The intelligence, gathering and feeding that in and the issue about time.

C

Efficiency in relation to this., So I think all of these will be recognised, but we need to take it away from this.

C

Meeting and make sure it feeds into those processes.

C

I do think this issue and you're right where you began, Camilla, I, think lots of.

C

Us in health and care think in generalities about what is it we're doing,.

C

But people live this in specifics and in the detail of this and somehow we need.

C

To make sure we're constantly making that connection between the generalities and the specifics.

C

But I think we should take it. On.

C

Similar issues around whistleblowing about does every whistleblowing.

C

Investigation, does that connect with the inspection plan,? Are they informing the key lines of inquiry?.

C

I think, as we take these systems into maturity, we need to make sure that.

C

They're, actually, both efficient but they're, making those connections as well.

C

So one of our previous responses in relation to whistleblowing cases,.

C

We've now made it mandatory that all inquiries into the NCSC should actually.

C

Be signed off by a inspector on the customer relationship, database.

C

So there shouldn't be anything that looks like it's lost,, so we need to take.

C

This this away and actually make sure those disciplines are in place as we.

C

Move forward with the work we're doing.

C

So I think these are good and important. Points.

E

≫≫ Just a couple of points.

E

I think it would be useful to think about all the kind of points where people touch.

E

Our organisation,, whether it's members of the public or others, and particularly.

E

When they're telling us stuff or wanting information.

E

Looking at it from that perspective would be good.

E

The other is expectations,. They do find it very hard that we want to know about.

E

Their complaint, if you like, but then we don't investigate all the individual circumstances.

E

We will have to be very careful not to raise expectations, because that has.

E

Happened on a number of occasions, and we need to be careful with it.

E

We definitely need to be responsive and clear and get our processes right.

E

But, if you've lost a child- and you think CQC is going to give you the answers.

E

You want, then,, you know,, and we kind of let them believe that for a while.

E

Before saying we're not going to,, it's pretty devastating,, that's an extreme end.

E

Of it, but it's also being quite clear about what our role is as well as being responsive..

B

≫≫ Well I agree.

B

It's very interesting these cases, because I think the issues that you're raising.

B

Camilla are quite broad issues,, as well as specific about these cases.

B

Of course we can't do everything, but it should be possible when members of the public take a concern to us, for them to be on to the next stage as a result of our action.

B

The difficulty you're describing is that when we say we're interested in.

B

Complaints --, incidentally, we do investigate some complaints,, don't we?.

B

Under, the Mental Health Act. So, there's a greater anomaly that we'll investigate some but not others..

B

But, the real sting in the reply to the public is you've got to start again.

B

It, isn't just that we're the wrong organisation,. It would be much better if.

B

We were the route through which that complaint went to the ombudsman.

B

Or went to some other body.

B

When we say it's not our role, that people are being pushed back to square.

B

One and for people who are distressed or have a grievance,, that's a very poor.

B

Response,, however, we might intend it..

B

The. Second issue is the starting point for your first case, which is about.

B

Medicines management in care, homes.

B

I, do think this is a very important question for us.

B

None of those things would have happened if medicines management in a care home was good,. So let's not lose sight of the fact that this was not just.

B

About internal processes,, this was actually about what happened at an.

B

Interface between two elements of the service.

B

So: it's back to the issue of how we integrate two bits of the service.

B

When I went on an induction, inspection, I went to a care home and I thought it.

B

Wasn't a bad care home and I thought they inspected. It really well.

B

But the main issues, looking through a lot of the records were about the.

B

Medication, that was being used,, which seemed to be excessive and duplicating.

B

The trouble was the inspector wasn't expert on medication,? Why should they.

B

Be, they're, a social care inspector. The person in charge of the care home knew nothing about medication.

B

Except when they were supposed to give it,, because that was prescribed by a local GP.

B

One of the key elements of activity and safety at that care home wasn't even.

B

Examined because we didn't have the ability to do it and they didn't have the.

B

Ability to respond,, even if we wanted them to do.

B

So this question about how we look at our function. From the point of view.

B

Of the person who's receiving care and not through the individual providers,.

B

Is going to come back at us until we're able to resolve it.

B

We haven't got a person-centred inspection system and yet we're.

B

Expecting a person-centred care system.

F

≫≫ I take as read the work that we're doing on our internal complaints.

F

Processes,, though, I think it's taking quite a long time for us to get to the.

F

Point of progressing that,, so it would be great to be able to get to the end of that piece of work..

F

But I think there's, I mean I thought that was really, really interesting and really.

F

Helpful and rang many, many bells.

F

At Healthwatch England. We get a surprising number actually of people.

F

Who come to us because they've got desperate because actually there's.

F

Nothing that Healthwatch England can do either in these spaces, so there are.

F

People who have just been floating around the system, passed from pillar to.

F

Post who have reached that level of frustration which makes people more.

F

Inclined to dismiss them because it stopped being what you might describe as rational..

F

It's, a perfectly rational response to a completely irrational situation.

F

And, they just feel they've been pushed around the spin dryer endlessly.

F

I, don't think we will --, we could have a great process for handling all of this.

F

Internally and feeding it into our inspection processes and so on,, but we.

F

Will not resolve this question of what happens -- the issue of not being able to.

F

Investigate -- not being the right place actually to investigate complaints at that.

F

Level of individual detail and giving them a response on the individual detail,.

F

Unless we orchestrate more of a system-wide conversation about how that happens.

F

I'm not sure I agree that it would be better if the CQC investigated those.

F

More complaints, I'm, not sure the CQC is the right place for that to happen.

B

≫≫ I said you shouldn't have to then go to someone else.

F

≫≫ No, I understood but I, don't think the system as a whole has resolved, who.

F

They think is the right place. So. There was a piece of work which was done in the context, Clwyd Hart and then responses in hard truths on complaints and to be truthful. What there.

F

Is in hard truths is a set of activities around complaints,, so it's a patchwork.

F

Of bits of work,, but none of these truly address the question of how do we.

F

Manage the fact that individual complainants are finding their way to.

F

Sometimes, to NHSE, sometimes to CQC, Healthwatch England, PHSO,.

F

Or the LGO, all over the place.

F

It's, not really surprising,. We did a map of how many players there are in the.

F

Health and social care complaint system and there's more than 75 organisations.

F

Or types of organisations. That doesn't account for the fact there's, 148 or 150 of various different kinds of organisations.

F

These are types of organisations that have a role to play in complaints, so it's.

F

Incredibly complicated and it's absolutely not clear where we should be sending.

F

People to, actually,, you know, even if we act as a portal and support their being.

F

Passed to an appropriate person,, it isn't clear to everyone how that should happen.

F

Arguably there's a really simple bit,, which is you start with the provider,.

F

If you don't get what you want, you go to the ombudsman,, but it isn't quite like.

F

That,, it's more complicated than that.

F

So, we would argue at Healthwatch that what you need is a really good advocacy.

F

Service and the person you ought to pass people to is someone who can help.

F

Them through the system. So someone who guides and supports them and acts on their behalf.

F

But that advocacy service, such as it is at the moment,, is very fragmented,.

F

It's different in health and social care, in mental health and different for children.

F

So that, in itself, is not a good quality of highly visible service to support people.

F

Through complaints. So, I mean, that is to say, I, think there is a really big question which the system.

F

As a whole hasn't resolved and which I'd really like to see the CQC playing a part.

F

In getting the answer, to.

F

Not- that we should be the answer, but there needs to be an answer to these.

F

Fundamental questions about how the system as a whole deals with complaints.

G

≫≫ Thank you,, just two or three points and Annie may want to pick up on this more directly.

G

But, one of the things we have announced recently is the agreement.

G

Between ourselves and the local government, ombudsman and the health.

G

Service ombudsman that if, you know,, calls come through to us that ought to.

G

Be going to them and vice versa,, we make those direct transfers, without.

G

Saying no put the phone down and ring somebody else.

G

So. We are trying to facilitate a better service and response to people. Who,.

G

As Anna quite rightly says, get into the system at different points, and that might.

G

Not be the right bit of the system.

G

The second thing: I just wanted to say was that to go back to I, think one of the.

G

Comments that Camilla made early on, which was very often when things go.

G

Wrong, people want to make sure it doesn't happen to other people,, so the.

G

System learns from it and actually makes a difference. And that's where our.

G

Role, I think,, we can be very clear and explicit, can be, because in actually.

G

Taking regulatory action, either through inspection or, however else we do it,.

G

We ought to be kind of putting into the system the signposts really that can.

G

Help to make those changes so the broader issues get addressed even if.

G

We're not resolving the specific issue for an individual.

G

So, that makes it even more important for the third point: I wanted to make,.

G

Which is that our own intelligent monitoring, but also management and.

G

Assessment of risk kind of works really, really well and that that's one of the.

G

Issues both through the changes, you know,, we're making through the.

G

Structures within the organisation to enable a much better support for our.

G

Inspectors and our inspection teams, and also from Paul's team in intelligence.

G

To make sure we're actually using the information better to flag those things up.

G

And to flag up the risks and we're not completely there yet and, you know,.

G

Thank Camilla and others for raising some of these issues with us, because.

G

Each and every time we can make incremental differences to make it better.

G

And that's very helpful.

G

But, that's kind of one of the areas,, particularly in adult social care,, that we're really focusing is. How are we managing our risk registers, so that.

G

People are generally aware of this and responding properly and making sure all of those dots join up.

G

Certainly in the example Camilla's given,, we did not join up the dots as well.

G

As we could have done.

A

≫≫ One other question and I'll. Let Camilla have the last word on this, Paul.

A

I think and then Camilla.

H

≫≫ We talked about the operational changes we will make and are starting.

H

To make, and also the changes that are really about the service we deliver to.

H

People who contact us and raise concerns of customers; customers isn't.

H

Quite the right word,, but it's more around that mindset.

H

We've also got the opportunity on the policy. Side.

H

David mentioned the key lines of inquiry that we're changing to be more.

H

Responsive to people who raise concerns, but with the new regulations.

H

Coming in to play from October around fundamental standards,, we've got an.

H

Opportunity around our enforcement policy very shortly to look at the.

H

Conditions under which we will explore, or what has happened to an individual if.

H

An individual has suffered degrading treatment,. We can prosecute.

H

That's, the purpose of the new regulations and the move away from a.

H

Central standards to fundamental standards.

H

It may or may not give total recourse to the individual, depends what they were.

H

After, circumstances are different,, but that ability to hold providers to account.

H

For individual failings of care, as well as systematic ones, I think is quite important..

D

≫≫ Just one last point that strikes me, as a result of the conversation,.

D

We are fundamentally a safety organisation,, we're not a complaints.

D

Organisation, we need to deal properly with complaints, but I do wonder.

D

We're quite good -- I suspect it's a slight cultural thing,. If we think it's a safety.

D

Issue,, we go and look at it and we try to get a grip of it, I. Just wonder whether we.

D

Need to be a bit careful that we don't think of some things as complaints and.

D

Other things as safety,, because the two cases I've given are really about safety.

D

What I was trying to say: is that sometimes our response as an.

D

Organisation, to what we see as complaints is somewhat defensive and.

D

Our desire is to make sure the person's happy and smooth it all over,.

D

Rather than actually get to the safety, issue.

D

I do think we need to keep that in mind when we're dealing with our.

D

Complaints process,, we don't put it in a separate box.

C

≫≫ James Titcombe made that point in the select committee yesterday, about in the nuclear industry. They actually deal with that as feedback about safety issues,, not as a complaint to be made.

C

So. It's a powerful resonance of that.

C

Not to have the last word, David,. There's one of our managers called Caroline. Jenkinson who's been dealing with a father whose daughter had a.

C

Eating disorder, who died, and I have to say, she's, been dealing with him over.

C

About 9 months and I think it's a brilliant piece of humane work,. So your point.

C

About? What's typical and not typical,, not to deny those stories, which are also.

C

True, but I see lots of people now and a lot of our letters to MPs,. We've left.

C

Behind this cold style that we've had and they'll have the inspector or the.

C

Inspection manager dealing with this is...,, their name goes in, their email.

C

Address and the mobile telephone,, so that gives the MP, and indeed some.

C

Constituents, the opportunity to go back to people and I think that is a significant.

C

Advance on what we've got.

C

I think, what the stories pull out is a huge variation that we've got across the.

C

Organisation and I think it's a challenge, and I'm absolutely with Paul and I. Think.

C

On the systems-wide stuff,, we are part of the DH group overseeing this, and it's.

C

For the DH not to start dumping responsibility, but if they're holding the.

C

Line on the framework,, then we may need to make a contribution,.

C

So we are represented at a senior level, (inaudible), as Director of Strategy.

C

Attends that group for that very specific opportunity.

C

So item four is the Crown Prosecution Service.

C

I wrote in here, "the board will recall" and I strongly suspect the board will not.

C

Recall, because I don't know that there's anybody on the board, apart from Kay, that goes back...

C

It's, even before my time is this, I think as well.

C

So there was a case where an inspector had been found to have actually been.

C

Involved in corruption, they'd been accepting money in return for.

C

Guaranteeing inspection outcomes to a provider.

C

That was identified internally by staff and it was referred to the police,.

C

The police investigated, it went to the Crown Prosecution Service, who took a.

C

Decision not to prosecute because they deemed it not to be in the public interest.

C

John Harwood was incredibly concerned,. I think you were as well Kay,.

C

In relation to this, and there were a sequence of letters that went to the CPS.

C

In relation to this over a 12-month period, raising our concern at the.

C

Judgement of the CPS that this was not in the public interest.

C

Our view was, this was absolutely in the public interest, and a prosecution should have resulted.

C

As a consequence of the last letter we sent, Rebecca and myself met with a.

C

Senior colleague from the Crown Prosecution Service, who is now in a.

C

Different job, but prior to that, had been in the special investigations branch,.

C

Who had reviewed all the correspondence and the paperwork in relation to this particular case and who did say that that decision not to prosecute was wrong.

C

He accepted it was in the public interest to prosecute, apologised to us for not.

C

Doing that and we then had a conversation which Rebecca's been.

C

Taking forward about what's the relationship, we need both with the.

C

Local police in relation to these cases, historically we've had a relationship with.

C

The city of London, because that's where we sit, and I, think the outcome of this is we'll develop a relationship with the Met, and City of London and also setting.

C

Up a relationship with the Crown Prosecution Service,, so we've got a.

C

More direct line of communication and contact with them as a consequence of that.

C

Because, this has been a big issue over a number -- well I. Think now, over a.

C

Number of years, I wanted just to draw attention, the board's attention to that,.

C

And say that Rebecca and other colleagues will work on how we can.

C

Develop that and then the last item, Chair, is the 3 Lives Report. But you and.

C

Louis,, if I'm, not stealing Andrea's thunder, have already stolen my thunder.

C

On that and said, it's being published, today.

C

It's a story of three individual lives and sets out some of the issues,.

C

The report that is published does have actions that are being taken and they're.

C

Designed to make improvements and a contribution across the system, in a way.

C

That the learning should be extracted from those three cases and taken.

C

Forward but I'll leave that there. Thanks chair.

A

≫≫ Thanks very much,, David., Paul, Lelliot and Caroline Hackett here for the next, but one item,. So can we.

A

Take the reports from the chief inspectors as read and ask questions on.

A

It rather than going through them in great detail,, unless there's any particular issues that Andrea or Mike wanted to pull out of them.

I

≫≫ To have mine taken as read, I'm very happy to answer any questions.

A

≫≫ Andrea, did you want to bring anything out?, >> Any questions for Mike?.

E

≫≫ Andrea on the covert surveillance,, which obviously is becoming quite a big.

E

Issue with very polarised views on it and I just wanted to clarify, you know, what.

E

We can actually do as an organisation because we can -- in legislation. We can.

E

Do covert surveillance is that right? And there's a code of practice and you know.

E

So that would have to be sort of instigated if we went down. That line is.

E

That right? And, also, where are we on that issue- that the covert surveillance?.

G

≫≫ Thank, you very much Kay. There's, two aspects to the covert surveillance, question: one,.

G

What can the Care Quality Commission do and, secondly, what generally happens.

G

And what advice and guidance should we be giving to the industry?.

G

As we've highlighted in the report,. There is a range of views about this,, which are.

G

Both polarised in some respects,, but also lots of shades of grey in between.

G

Where we plan to get to is reviewing all of the feedback that we've had through.

G

Consultation and the round table we had with a number of different stakeholders,.

G

There's another event that the relatives and residents association are going to.

G

Organise in July,, which will bring together another round of discussion of.

G

Interested people in this subject.

G

Looking at our powers,, we do indeed have those powers already and we are.

G

Working through what are the circumstances where it might be.

G

Appropriate and being very clear and explicit with ourselves about that.

G

We've got a workshop with inspectors later on this month to kind of talk.

G

Through the practicalities of all of this,, because there's no point us coming up.

G

With a policy position that makes no sense on the ground.

G

So, we'll probably come out with something, but at the stage where we're.

G

Issuing the provider handbooks that do that.

G

The second issue,: the social care providers are very interested in what our.

G

View is of covert surveillance, in terms of how they might use it and again, I think.

G

That, although there are different positions,, the consensus seems to be.

G

Emerging around if there are specific issues of potential harm, either through.

G

Abuse or neglect,: this is the only way you'll be able to find it out,. Then those.

G

Circumstances, it might be appropriate,, but there needs to be very careful.

G

Consideration of people's dignity, privacy and their capacity to consent,.

G

All of these sorts of things,, and so our plan is to work through with others.

G

Including the commissioner, around some form of a guidance note around.

G

That and again we would look to doing that later on in the year.

G

So, it's still work in progress, but that's what we're doing.

F

≫≫ Sorry just a question also for you: Andrea, on the registration, process.

F

So there's a reference in the report to using experts by experience in that.

F

Process, I wonder if you could just elaborate on how that might work?.

G

≫≫ So we're looking at that at the moment and looking at part and parcel.

G

Of our approach to the regulation and inspection of all of our services, starts.

G

With a rigorous and robust test at registration and ensuring that we're.

G

Actually, applying the same level of rigour to registration, inspection, visits,.

G

As we are to inspections of services, once they're up and running.

G

We're interested to find out what additional value experts by experience.

G

Can add to that, both in the questions that they might be able to ask and the.

G

Sort of assessment of the application for registration and that's working through.

G

At the moment, and again it's more work in progress.

G

There's lots of things going on, but we will be evaluating how that does work.

G

And whether it's appropriate to roll that out.

G

We have been using experts by experience in the registration of services.

G

For people with learning difficulties as part of our response to what's been.

G

Happening at Winterbourne View and the other cases that our 3 Lives report highlights.

G

So we've got some experience,, but we're trying to work --, develop it further.

B

≫≫ Andrea, could I just ask a question about Orchid View?.

B

Since we last met, our report's been published,. The local report has been published.

B

I must say: I was struck by the response of the families in the media and the.

B

Families who are affected, the people whose relatives died,, because.

B

They went further and said what they wanted was a public inquiry.

B

Now, we live in an era where people want public inquiries and it's a common.

B

Request, but I think we've got to try to understand what it was. They were.

B

Saying when they said, that.

B

It suggests a dissatisfaction with the process, there's a sense. There's.

B

Something fundamentally wrong with how care homes are operating for some.

B

People, and that even an investigation,, the one's that been done in Orchid View,.

B

Doesn't quite get to the bottom of it.

B

I think when people say we need a public inquiry to investigate that, what they really mean. Is that there's something behind all of this which we're.

B

Not quite getting to and therefore we don't have the confidence that.

B

The fundamental problems are going to be addressed, because we're not sure they've been identified.

B

Whether, that's something to do with the financing of care homes that we were.

B

Talking about at a meeting last night,, whether it's about the training of staff,.

B

Whether it's just about the way that families are listened to, but I think they.

B

Were saying something important about their confidence,? That the fundamental.

B

Difficulties of care homes are being properly addressed.

B

I thought our review in the end was very good,. But if you look at what the local.

B

Review said,, it was a very sensible review,, but what it called for was named.

B

Staff, contact details,, better CPD, for guidance and when relatives have died.

B

These sound, like quite small measures, compared to the enormity of what's happened.

B

So, you can understand why the families are saying,. Isn't there something more fundamental that has to happen here?

B

And? How do we have the confidence that it will take place?

B

Now? What can we do about that?.

B

One thing we could do is formally review whether change has happened in our.

B

Own systems,, but also in some of the other recommendations from the report into Orchid View.

B

I don't know if we have a plan to report back at a certain point, as to what is.

B

Different in four months or six months,, so what is different as result of.

B

Orchid View? And to bring that back to this board.

G

≫≫ Thank you. So a few things kind of come out of that Louis.

G

I think that the first and foremost thing to say is that the experience of the.

G

Families was awful and both at the time and subsequently in terms of.

G

Understanding that some of the concerns they'd had at the time and.

G

Expressed at the time were indeed right and neglect had contributed to five of.

G

Those deaths and other people had died, having had a very poor and.

G

Unacceptable levels of care., So I think that the anguish with which they've obviously had to live was coming.

G

Through last week, and we've certainly made contact with the families,.

G

Adrian Hughes, deputy chief inspector for that area has met with them, we'll do that again.

G

In terms of responding to them as individuals, having had an awful.

G

Experience, I think it's very important that we respond to that with the.

G

Humanity that that deserves rather than,, as we were discussing before,.

G

Hiding behind the bureaucracy of our realm.

A

≫≫ Robert,, maybe just to get your perspective on this.

A

What Louis, is saying resonates with me.

A

People feel that the system is just not addressing the fundamental problems.

A

That is affecting these people.

J

≫≫ Well I think that's right. I mean there is obviously a tendency to demand a public inquiry for everything.

J

But I think Louis has a good point..

J

One thing I would add. Is that I think that a lot of the time people feel that those.

J

Who should be held to account are getting away with it.

J

I'm not saying they are or they're not,. That's the feeling.

J

Unfortunately they're often a little misguided in feeling that a public.

J

Inquiry's going to do any better in that particular regard because there are.

J

Other processes through which that needs to happen.

J

Also, maybe there's a feeling that the enormity of what they've suffered is.

J

Not being properly recognised in public.

J

It's, a public element which is not satisfied by what goes on behind closed.

J

Doors and a review, and so on.

J

It's all people, judging themselves,, that's the other issue. They tend to look at.

J

Although, obviously, in these safeguarding cases there is an independent element in what happened.

J

Also they don't quite understand the process. So there are all those things gathered up in it.

J

I think principally I would say it's the recognition to them and the public in.

J

General of the wrong that's been done and the feeling that no-one's been held.

J

To account are two powerful drivers towards a demand for a public inquiry.

J

Although in both instances,, almost invariably in my view,, unless it's a real.

J

National issue,, better ways of dealing with it.

G

≫≫ Just to answer the specific points from Louis, on Orchid View. In terms of.

G

The recommendations, there are some recommendations that are made for.

G

Us,, the vast majority of which are already incorporated in our own internal.

G

Review and action that we have taken or are already taking.

G

There's a couple where I think we've got to do a little bit more thinking, through,.

G

As to how we apply that to the world that we're now in, as opposed to the world,.

G

That we were in in 2011,, so my plan was to bring that back to the board and to be.

G

Absolutely clear and explicit what we're doing in response to those.

G

Recommendations,, but to take the broader point, I think that one of the.

G

Things that we can do, as the CQC, is use the State of Care report when we do.

G

That, in a really meaningful way,, because we do, I mean we have the.

G

Most amazing insight into what is happening in both the adult social care.

G

Sector and the other sectors that we regulate,, which we report on through the.

G

State of Care, report, and I think that that's the place where some of these.

G

Broader,, more national issues can be drawn out and highlighted, and that's.

G

Certainly, the intention that we've got as to how we would use the State of Care.

G

Report this year is to kind of use that to identify some of those things and that,.

G

I think, is a very powerful way for us to be sharing the broader learning that we.

G

Can have from the work that we do.

A

≫≫ Last question and make it quick.

F

≫≫ I'm really sorry,, it's just a reflection on what Robert was saying,.

F

Which I think is really important.

F

That part of the reason why people call for a public inquiry is because they want.

F

To give public account of their experience in a way that they don't in a private review.

F

So I just wonder if there's something we could and should be doing in terms of.

F

Our own review process, which includes an element of having that kind.

F

Of a hearing of what people want to tell us, but doing it in a public environment,.

F

However, we do the rest of the review,, but then that takes me to another thought which is, perhaps there's a conversation that would be useful to.

F

Have with the families at Orchid View about what would have made the.

F

Difference for them in the way that the serious case review was carried out and.

F

Made them feel that they didn't need to call for something else,.

F

Because maybe they'll have some concrete ideas about things they would.

F

Have liked to have happened or the way they would have liked it to have happened,, which we could then build into our process going forward?.

G

≫≫ Which is fine, but I think we do have to remember where the responsibility for.

G

Both commissioning and the serious case review is, and it's with the adult.

G

Safeguarding board for the area and certainly again they've had a lot of.

G

Interaction and liaison with the families and I know that that's --.

G

They're intending to continue with that.

G

I think the thing that we certainly need to do, and it came out loud and clear from.

G

The families is think about what would have made it better for them in relation.

G

To the interaction with CQC and absolutely clearly- and it goes back to the.

G

Conversation we had earlier, it's about listening to what they're saying.

G

And responding and taking that into consideration in the action that we take.

G

Through regulation and inspection, and that's one of the areas that we have.

G

Control in terms of how we do it and what we should do and is absolutely.

G

Built into the approach that we're taking as we're going forward.

C

≫≫ Andrea in her report, says we'll bring back a report to the July board of the.

C

Actions to follow up on the serious case, review and I wonder whether we should.

C

Add to that the Care Act and the powers that are introduced by the Care Act that play to this point.

C

There are two things that come out, one is that now adult safeguarding.

C

Boards are put on a statutory footing,. This is Andrea's point,.

C

They are the mechanism to actually take this forward.

C

The second, one is, I think one of the tools that the Care Act introduced,.

C

Is a fit and proper person.

C

The area in which I live, gets a regional television, so I got all the interviews with.

C

The families on the regional news when the Orchid View report was.

C

And Robert's point is; what I heard the families say was they wanted? Somebody.

C

To be held to account for it, and that was a very powerful message. Through the.

C

Interviews,, albeit edited that came through.

C

The difficulty on this,, with it being a Southern Cross home, those people, no.

C

Longer exist because Southern Cross is not quite gone as a legal entity. I.

C

Understand,, but is virtually gone.

C

But, a fit and proper person test allows any of those people that were in those.

C

Senior positions in Southern Cross,, the boards they're, currently working within,.

C

The chair of that board to take a view on whether, in light of what happened at Southern Cross,, they are indeed fit and proper people.

C

So I think one of the issues --. We need to work out how we're going to take that.

C

Forward and what that means in terms of our powers.

C

One of the themes that we talked at the dinner yesterday evening was how.

C

Proactive or reactive, we're going to be with some of these new powers.

C

So I think part of the bigger debate is: how is the Care Act going to be used.

C

And how we take that forward and whether collectively as a board, we.

C

Understand what has been provided to us by the Care Act and the detail of the.

C

Care Act and I think there's a bigger piece of work that we need to do about.

C

Do we understand the full implications of the Care Act and what tools it might give.

C

Us,, whether people will regard them as adequate or otherwise,, they are tools.

C

We've been given and we need to work out how we're going to use them.

C

I'm, looking at Paul as well as Andrea in this,, is when we bring this back,.

C

To open up a bigger conversation about how the tools in the Care Act need to be.

C

Used and I think that needs to be not just a board level. Discussion,.

C

But it needs to be a discussion that takes place with managers, inspection.

C

Managers, inspectors, as well as we go through,, and this is one of the issues we.

C

Would have taken forward through the academy,, but it's one way of picking up.

C

On this issue about what are we doing about it, I think is your question. Anna,.

C

And what is it legitimate? We do about it.

C

I, think, there's lots of things that are legitimate, that we need to do about it to follow it. Through.

C

Some of those are new to us, what the fit and proper test means and how that's.

C

Applied; and people will say it doesn't go far enough, but parliament has now said.

C

That's a tool we're giving you, make it work,, so we actually need to work out.

C

How that's going to work? It strikes me, rather than saying it doesn't do.

C

Everything that people want;- that might be true but we've got it and we need to use it.

C

Not in 12 months time be sat in conversations at a Health, Select, Committee or elsewhere. Saying we gave you this tool. Why have you not used it?.

C

So I think we need to proactively pick that up and it's just to connect the finer.

C

Detail from this report with some of the things we need to do.

A

≫≫ Thanks David,, thanks Andrea.

A

Next item is on the Mental Health Act.

A

Mike. Are you going to introduce this?.

A

≫≫ I'll introduce my colleague if I may and then hand over to them.

I

Paul Lelliot, who almost everybody on the board will know, is deputy chief.

I

Inspector in the hospitals directorate but leads on mental health, and Caroline.

I

Hacker beyond him, is relatively newly appointed head of mental health. Policy,.

I

Can I also introduce two others who are there as well, Pauline Carpenter, who.

I

Leads on Mental Health, Act operational issues and Simon Wood, who leads on.

I

Soads, so I think we have a good team here to talk about what we need to talk. About.

A

≫≫ If, you want to contribute, you haven't, got a mic,, so just come down to where.

A

Paul is, and don't be reticent, there.

K

≫≫ Well. Thank you very much., I'm, going to speak just for a couple of minutes to the paper and then obviously invite questions for discussion.

K

As, well as being the regulator for health and social care providers in England,.

K

The Care Quality Commission also has duties under the Mental Health Act and.

K

Also, as part of the UK's national preventative mechanism under the.

K

United Nations, Optional Protocol to the Convention against Torture,.

K

I'll refer to that as OPCAT going forward.

K

We've continued to discharge these responsibilities. During a time when we.

K

Focused much of our attention on developing the new approach to inspection.

K

I think, though, that now we're nearing the end of the development phase of the.

K

New approach,, it's a good time to take stock of how we're discharging our.

K

Responsibilities under the Mental Health, Act and OPCAT,, but also to review the.

K

Extent to which we can integrate these duties with our work to inspect.

K

Health and social care services.

K

What, we're putting before the board is a proposal to establish a board to oversee the work.

K

Just to say a few words about the responsibilities that we have.

K

The CQC acquired our responsibilities under the Mental Health Act in 2009,.

K

When they were transferred from the Mental Health Act Commission.

K

We discharged these responsibilities through two principle: routes.

K

Firstly through our Mental Health Act commissioners,, who each year visit.

K

About 1,300 wards, in which people are detained, and as well as making visits to.

K

Wards and talking to patients who are detained,, we are also responsible for.

K

Reviewing complaints relating to the application of the Act, and we also.

K

Receive notifications of deaths of detained patients.

K

The second principle way in which we discharge our duties are through the.

K

Second opinion appointed doctor, service, I'll refer to that as SOAD going forward.

K

And, this comprises about 120, consultant psychiatrists, who make about.

K

12,000 visits to places where patients are detained under the Mental Health.

K

Act and their job is to give a second opinion about treatments given under the Act.

K

We're also responsible for producing the annual report about the use of the.

K

Act, and we're also expected to advise the Department of Health on any.

K

Changes to the code of practice to the Mental Health Act.

K

Our role as part of the national preventative mechanism under OPCAT,.

K

We're expected to make regular unannounced visits to places where.

K

People are or may be detained on the grounds of mental disorder.

K

This does include locations that are registered for the Mental Health Act,.

K

So it is mental health wards,, but it also includes places of de facto.

K

Detention, which extends that responsibility to care homes and to all.

K

Nhs and independent sector hospitals, both mental health and acute.

K

These are places that may use deprivation of liberty safeguards under.

K

The Mental Capacity Act.

K

Now,. We consider that we discharge our responsibilities under OPCAT through.

K

Our Mental Health Act monitoring activities and through our programme of inspections.

K

What, we're proposing in summary, is firstly to four years after or five years.

K

After we took on these responsibilities to determine how effective we are in.

K

Discharging our responsibilities under the Mental Health Act.

K

We want to develop and then implement a plan for integrating our Mental Health.

K

Act functions with our new approach to inspection, and we want to do this,.

K

As far as possible,, without adversely affecting the discharge of our duties,.

K

Under the Mental Health Act.

K

During that work we'll identify any duties under the Act that we cannot fully.

K

Integrate and ensure that these are discharged, optimally.

K

And finally, I think we want to continue to develop clear policies and processes.

K

About how we deliver our OPCAT responsibilities.

K

And as I say,, we believe that this is being done through our Mental Health.

K

Act monitoring work and our inspections.

K

What we are presenting is a timetable for the work,. The timeline aligns with the.

K

Implementation of the new Mental Health Act code of practice in April 2015.

K

And as well as the proposed work,, we would continue to work closely with.

K

Those at the Department who are revising the code of practice.

K

That's really all I want to say,, obviously happy to answer any questions.

A

≫≫ Thank, you very much. Caroline,. Did you want to add anything? >> No,, that's fine.

A

≫≫ Questions for Paul?.

E

≫≫ I, actually don't have questions, I'm, obviously very pleased that this paper.

E

Has come to the board and it shows that we're taking the issue seriously.

E

I think my overriding message is: we need to sort of get on with it, frankly.

E

Obviously we need to do it properly and I just need assurance that it's doable in the timescale.

E

So, it would be good to have that assurance.

E

I suppose it would be good to know what the final model is likely to be because.

E

I'm aware that quite a lot of work has been done over the years and I'm not.

E

Actually sure, where all that's gone to be honest and whether any of it is currently relevant.

E

So, it would be quite good to have a clear model as soon as possible.

E

The only things I would say is I agree that the Mental Health Act functions do.

E

Need to be integrated,, but we do need to make sure that we maintain the focus.

E

On the Mental Health Act, and that we don't dilute it.

E

And I'm pretty sure we've got people who will make sure that doesn't happen,, but I would firmly endorse that view.

E

That doesn't mean we have to do it in the same way that we've always done it.

E

I think we can be quite creative if we want to be and I'm sure people have ideas.

E

There has been a tendency to focus on wards and in-patient units,.

E

Partly because that's what's always happened, and partly because it's easier.

E

And I know: we've done other bits and pieces.

E

But. Obviously it's not just about the in-patient, but about approved Mental.

E

Health Act social workers and section 12, doctors, and section 136,, so it would.

E

Be good that when we're doing our monitoring that we do actually look at a.

E

Pathway approach as well.

E

So thank you, I mean very keen to get on with it and also, as soon as possible,.

E

Get a clear idea of what the eventual model will be.

E

K

≫≫ Yes, I can respond. Briefly.

K

I absolutely share your view that we have to give very close attention to our.

K

Responsibilities under the Act. I think since I've been in post I've not noticed, there's been any lessening of.

K

Effort and vigour in that regard,, but there's always a risk given our huge.

K

Focus on the inspections.

K

And. Thank you very much for expressing your confidence in the people. Involved, I share that.

K

I think we have the staff in place to see that through.

K

We're also going to ensure that there's a senior person within the hospitals.

K

Directorate who takes a lead on the Mental Health Act, so the focus is maintained.

B

≫≫ This is more of a comment,, partly because it's been a feature of this. That.

B

We've been able,, Kay and I, to work with the mental health team. Very well,.

B

So they've consulted and come for comment and advice, which is a very.

B

Helpful part of the way this is working.

B

Can I just emphasise a couple of things that I think will be vital in how we review.

B

Our function under the Mental Health Act.

B

There's a sense we haven't been very good in the past at getting the right.

B

Information and information is king in this area, amongst many others, and we.

B

Don't have very good information on when people die under the.

B

Mental Health Act and why. Yet there are about 300 deaths under the Mental Health Act,. Most of them are.

B

Natural caused deaths,, but that doesn't mean they don't include preventative.

B

Factors which could be addressed by better care.

B

Getting information about that will be crucial..

B

There is still some dispute about who should investigate those deaths,.

B

As I understand, it, we're not absolutely certain where an investigation into a,.

B

For example,, a restraint related death might be carried out.

B

To give it the right degree of importance and independence.

B

So there. Some questions about investigating mortality under the Act.

B

This ought to be the most important thing that happens in the entire NHS.

B

These are people whose rights are removed,, some of them are, for their.

B

Own benefit,, in order to provide them with better care and that's almost a.

B

Unique situation across the healthcare system,, so we have to ensure that when.

B

That goes wrong, and they die while being detained under State powers,.

B

That we are doing the right thing to find out why and to learn from that.

B

So, that's one thing, alongside mortality, there's the issue of rights.

B

Our reports over a number of years have looked at what people have said in.

B

Response to questions about rights, but I, don't know whether we've systematically.

B

Examined how people's rights are being respected.

B

It's, a fantastic volume of inspection we carry out under the Mental Health Act,.

B

But whether we use all the information that then becomes available to check.

B

How people's rights are respected, I'm, not so certain.

B

We now have advocates --. We ought to have Mental Health Act advocates across the system, who would be a good source of information as to how local Trusts perform.

B

Thirdly there's the issue of what the Mental Health Act achieves, reports tend.

B

To focus on what's negative,, but if the Mental Health Act isn't achieving.

B

Something positive,, then we probably shouldn't have one.

B

So. It's important. We set out what it achieves for the confidence of patients,.

B

Their families, and for the staff who will apply it.

B

Finally there is the issue of whether there is a benchmarking function. We could carry out.

B

Local organisations are always keen to know how they perform in comparison.

B

To other people,, their neighbouring Trusts for example,.

B

And we ought to have the data on that.

B

So, we don't know whether it's good or bad, when section rates go up, but we.

B

Should be able to say whether it's happening in one Trust or in several,.

B

And maybe what the reasons are.

K

≫≫ Yes,, if I, can sort of relate my response also to the question or the.

K

Point that Kay made about the timeline.

K

I'm, anticipating by next April, we'll have done a lot of work on the fundamentals.

K

But there's almost certainly going to be programmes of work that go way beyond that,. Looking at the datasets that underpin the Mental Health Act and how.

K

We relate to other activities in the wider system, including around the review of.

K

Deaths of people under treatment and under detention.

K

I'm, certainly not suggesting everything will be sorted by next April,, but what we.

K

Would have done certainly is identified. The work programmes that take us beyond that, to the point you're describing I think, Louis.

J

≫≫ David, I just have a question really about the Mental Capacity Act and.

J

The deprivation of liberty, safeguards.

J

My understanding, is that a recent court case has extended the ambit of what.

J

Had previously been understood with regard to who is subject to or entitled to.

J

Benefit of such safeguards and I wonder if that's increased the potential scope of.

J

Work that the Commission has to do?.

K

≫≫ I don't have an answer to that question yet but I think. As we say in the.

K

Paper, I certainly think the Care Quality Commission has to review its policy.

K

Position in relation to detention and de facto detention,, including places where.

K

Dols can and are applied and I think we need to check that. We are.

K

Discharging our full responsibilities under OPCAT.

K

We, don't have the answer, I think we need to have the answer as soon as possible.

A

≫≫ What's your view on that Robert? How, many more people will it catch?.

J

≫≫ The case is called Cheshire West and it is decided that these safeguards.

J

Apply to people who had previously been regarding as voluntary residents in.

J

Homes, and even if no-one locks the door,, if functionally, they cannot move,.

J

They are being considered to be deprived of their liability and my.

J

Anecdotal information is that the Court of Protection is currently receiving a.

J

Huge number of cases in relation to this sort of activity,, which previously had not.

J

Been thought to be requiring such a level of scrutiny.

J

I, don't know what the numbers are or anything like that,, but there's a perception. I've got in the legal world that this is causing a lot of business. So I.

J

Imagine it ought to be here as well.

C

≫≫ If I may. So. This was a Supreme Court judgment,, which was the Cheshire West case,.

C

And we circulated to the board in the Friday briefing the fact that this.

C

Judgment had been arrived at there were some implications, and Robert's point about its extension,. One of things that we did is we issued some guidance.

C

To providers about how we'd take this forward and as this work in the Court of.

C

Protection and other places takes place,. Then we can complete the revision of our guidance.

C

But, one of our themes has been about how far the Mental Capacity Act and the.

C

Deprivation of liberty, standards features in all of our inspections, but.

C

Predominantly the hospital inspections and the social care inspections.

C

So I think that initial rush of activity that followed the Supreme Court.

C

Consideration of this, I think we've picked up,, but I think your point is that.

C

There's longer term implications and we need to make sure we've picked up those.

C

I think Rebecca's got hold of this, along with other colleagues as well,, so I think.

C

We've filled the immediate, in a sense, gap that was created by the judgment,.

C

But there's more work to be done, and we'll be able to do it in the fullness of time.

A

≫≫ Thanks very much for that.

A

Paul. While we've got you here, just give us an impression of how the mental health inspections are. Going., (Laughter).

K

≫≫ Right, thank you.. We are coming towards the end of the wave inspections.

K

We've conducted onsite visits to five plus six, 11 mental health, Trusts and.

K

What I think we've demonstrated,, certainly to my satisfaction,.

K

Is that the general model that was developed in acute does apply in mental health.

K

There are obviously 101 details in how we've had to adapt the model to the.

K

Particular characteristics of mental health providers,, particularly the very.

K

Large, complex mental health services that are spread over 100 plus locations.

K

In a wide geographical area,, but the model works and certainly we're getting.

K

A very positive reception to the fundamental changes in the way the.

K

Inspections are conducted,, particularly the incorporation of large numbers of.

K

Clinical and service management experts in the team and experts by experience.

K

So, it's been tough, I can't pretend it hasn't been and I think that was the.

K

Case for the acute wave inspections, but I think we're going to be in quite a good.

K

Position come October when we're going to be inspecting in earnest and rating proper.

A

≫≫ Thanks,, thank you very much.

A

Thank, you all for the work you've put into it as well.

A

We're going to break now for a cup of coffee, thank you., >> Next paper on culture and values, Eileen.

L

≫≫ Thank you very much David.

L

You've got a fairly chunky and extensive paper with you that covers a number of things.

L

The first thing,, the Pulse survey,, which is the checkpoint. We do at the mid year.

L

To ask staff how things are going,, how they're feeling, it gives us a point of.

L

Comparison at a six-month period and about 600 staff took part in that,.

L

So we can take some discussion around that and the generally very pleasing.

L

Upward direction of travel.

L

We can touch too on a review that has recently been undertaken by Sarah.

L

Hunter- and some of you who were here last year and predate me,, will remember.

L

That Sarah came in to offer the opportunity to staff to talk with us and.

L

Share their views about issues particularly relating to behaviours and.

L

Concerns that they saw across the organisation that were impacting.

L

Negatively on them and they felt negatively on the organisation,.

L

And we made a commitment then that Sarah would come back one year later.

L

To make the same offer to colleagues to come and talk to her and we'd seek to learn from that.

L

Also and most critically,, you will notice. You have in front of you some lovely.

L

Blue cards and I think these were sent to you over a week ago or so,, which set.

L

Out part of our journey towards reworking the CQC values,, the values.

L

That the organisation is working with currently are,, at least three years old.

L

And obviously, if we think about CQC three years ago and the CQC now,.

L

It's an important time to think about. Do the values we've inherited, most of us,.

L

Reflect the sort of organisation that we are and that we will be, and so an.

L

Exercise has been going on which Jonathan Evans, who's with us today,.

L

Will talk about,, which has involved and engaged all of our staff in actually.

L

Thinking about what are the values that best represent our CQC and one CQC.

L

We set those out there for you and invite you to make your contribution in.

L

Terms of just highlighting the words that most resonate the CQC, you believe we should be.

L

We have made a very firm commitment to our colleagues across.

L

The organisation, that the consolidation of this exercise will be made public in.

L

Terms of agreement on CQC values and setting the agenda and the tone and the.

L

Behaviours around them on the 1st of July and again Jonathan can touch on that.

L

But I'd really like David to pass over to Tracy Dennison, our HR lead, and to.

L

Jonathan Evans, who have been leading on this work and who I know, can outline.

L

The highlights I suspect, but then take questions, working on the assumption.

L

That everyone's had a chance to go through what I know is quite a chunky. Paper.

A

≫≫ Tracy,: do you want -- I should have introduced you at the beginning.

A

Tracy Dennison who's head of HR.

A

You've been here two, three months?.

E

≫≫ Four months, now.

A

≫≫ Do, you want to add to anything, Eileen just said or just take, questions?.

M

≫≫ I'm happy to take questions, there's a lot of detail in the report. I know, but.

M

Happy to take questions.

A

≫≫ Jonathan, you're happy to take questions?.

M

≫≫ Very happy to take questions. >> Jonathan has led the exercise on values.

A

≫≫ So Kay?.

E

≫≫ So on the values,. It is actually part of the board's role to set the values but I.

E

Total agree: it needs to be an organisational thing. So, you know,.

E

I'm very glad that staff have been involved in discussing what the values are.

E

There are a couple of things: I'd say, one is whatever values we choose. I would.

E

Prefer ones that are,, if you like, obvious to the public as well, because.

E

Like accountability for example,, it is a good value to have,, but I'm not entirely.

E

Sure whether the public might fully understand that.

E

So, my preference would be to have, you know, simple one word things like,.

E

You know honesty is okay or trust for example, they're, quite good.

E

So thinking; something our staff identify with, but also the public can understand.

E

The only other thing about it is some of these are values, and some of them.

E

Aren't and maybe I'm just a bit obsessive, but it feels,. It feels odd when you've got.

E

A value and then you've got an adjective,, so I think it would be better if they were.

E

Actually, values, as opposed to adjectives,, because it grates with me,.

E

And it may well grate with others.

A

≫≫ Let's stay with the values then.

A

>> What. These are are words,, not values and they're. All joined together by.

J

The fact they're words,, but it's a different sort of thing.

J

I- think really the process we're going through to do this, which is an internal.

J

Process is a bit worrying, because, in effect, it's the external relationships of.

J

These values that will matter much more than the internal.

A

≫≫ Any other points on the values or adjectives or words?.

A

Oh, sorry, Louis.

B

≫≫ That's right. Can I, just check where we are with this?

B

It suggests we're going to launch the values on the 1st of July in the paper.

B

I would have thought -- without being too critical --. We need four or five values.

B

Rather than about 25 and to cut --, that cull of values probably needs a bit of discussion.

B

It's, certainly true that some of them aren't values,, but it I suspect it wouldn't.

B

Be all that difficult to get some of the really key elements of this into a shorter.

B

List,, but if we have to do it by the 1st of July, we might need to do it. Now,.

B

Or in the next week or so.,.

A

≫≫ I should have asked you at the beginning.

N

≫≫ I better just describe the process which may reassure people.

N

There's no intention to have 30 values.

N

We're, looking at somewhere between three and six.

N

The long list you have in front of you arose from a number of focus groups.

N

We held across the organisation, talking to people, listening to people,.

N

A little bit of research of other organisations,, a bit of my previous.

N

Experience in other organisations.

N

From that we've now had a dialogue,. What we call a dialogue with the.

N

Organisation,, where everybody has been invited to be involved and feeding in their.

N

Views and their words and the process now writing a report for the executive.

N

Team,, which they will get next week,, which actually highlights what are now the top ten.

N

It's not been a vote,, it's been a consultation,, but there are ten values.

N

That have come through loud and clear and I totally agree. They're just words.

N

Words are open to interpretation,. The important thing is not the value word.

N

Itself, but the behaviours they drive.

N

So in the report that I'm doing,- these are the top ones,. But these are the.

N

Behaviours, you know, "accountable". What does that mean? How? Does it look?.

N

How, does it feel? And? We talk about the values of accountability, --, the.

N

Behaviours of accountability drives and also, if we don't live by accountability,.

N

There are things that could go wrong in the organisation,, so it's all laid out in that particular piece of report.

N

So, the executive team, as a result of this consultation, will have the most popular,.

N

Is the best way of putting it, 10 with descriptions of --, simple tag line.

N

Descriptions of what the words actually mean, because it's open to interpretation.

N

All words are, simple tag line and then underneath a series of behaviours that.

N

They would drive and things that would happen if we got it. Wrong.

N

The dialogue closes tonight, across the organisation, spending all day tomorrow.

N

Finalising things, finalising the report,, which will go to David and colleagues on.

N

Friday, with a view to launching it on the 1st of July.

B

≫≫ The point about the public facing element of that, can I just check,.

B

Because in the end, I agree with people that have said that's what will count in the end.

B

Is that got to happen by the 1st of July, the checking out that this is what the.

B

Public want from CQC?.

N

≫≫ David and I spoke, I think earlier this week or last week about making sure.

N

That these are words that will also resonate with the public and that's very important indeed.

N

But the importance of values, --, there's two things here, one is it resonates with.

N

The public,, but also we want them to drive the right, behaviours,, the appropriate behaviours,, to enable this organisation and everybody in it to.

N

Relate, going the same way and drive towards the same goals.

N

I'm very conscious of the external need, but I'm very focused, also on making.

N

Sure that we are all going the same direction internally and can live to the.

N

Same values,, which I think is very important.,.

D

≫≫ Jonathan,, can you just remind us of what the existing values are, because.

D

These are obviously replacing the existing values.

N

≫≫ Some existing values are very similar,, there's -- integrity and.

N

Accountable are both there, pride. Is there and respect is there.

D

≫≫ Right, and what do we do? -- are those publicly known?.

D

I can't remember,. Do we put these on our --? We don't have it as a strap line. Do we?.

D

Where, do other people see those values outside the organisation?.

C

≫≫ I think one of the issues Camilla is that,. Notwithstanding the point that.

C

Paul's made about the public facing stuff,, but internally...

C

≫≫ Yeah, yeah, there are two separate issues: here. >> These were written and given to the organisation.

C

There was no process by which the organisation had a sequence of.

C

Debates and discussions.

C

So the process that Jonathan has just created, which has allowed teams across.

C

The organisation to have this discussion, arrive at their view, and this list is.

C

Really the product of many, many conversations that have taken place...

D

≫≫ Sorry,: that's not what I'm asking. I'm very sympathetic to the idea that we have an internal dialogue where people.

D

Feel listened to about what values of the organisation are, and that managers can.

D

Use those values to drive the right, behaviours.

D

What I'm, worried about and what I think Paul is worried about, is what we.

D

Do publicly with this,, which seems to me to be a different thing.

D

So, my starting point is just to stay. What are the existing values,? Is the public.

D

Aware of them, and therefore what are we saying to the public about how we're changing?.

D

I'm, just not clear on that part of it.

C

≫≫ They're not used because they weren't owned by the organisation.

C

The place they're used is all our recruitment literature, at the end of it has, and these are the values of the organisation, so they then dictate the job.

C

Descriptions,, which then dictate the selection criteria,, which then dictates.

C

Some of the conversations which have been going on.

D

≫≫ Okay,, so is there any need for us to publicly assert these values beyond the.

D

Internal needs of the organisation?.

C

≫≫ My personal view is yes, because we've just had a conversation about.

C

Openness and integrity and what we do when we're in a difficult position and.

C

That, for me, was a demonstration.

C

It's, no surprise that integrity comes out at 70 percent, when people have actually.

C

Expressed a view about what they want it to be., That may or may not be the right word and if you do the word association on.

C

This, integrity and openness,: are they the same,? Are they different?

C

So, there's some sequencing to do, but I think it is important that the words we.

C

Use have both an internal and an external meaning.

E

≫≫ Absolutely, I mean the old ones were imposed and they weren't owned. So it's.

E

Really good that the organisation has been involved in those, and I, don't know.

E

That we need to be very public about them because they drive our internal,.

E

The way we do things, but I do think they need to be understandable to the public.

D

≫≫ No, I agree with that. But I, wasn't sure how far we were proactively pushing this stuff out,, because that's where I would get a bit nervous. >> I, just don't know what your plan is.

J

≫≫ Part of the internal/external issue seems to be these words, as words,.

J

Could be describing internal behaviour,, that is how staff, board and so on, treat.

J

Each other or how the organisation treats the public.

J

Both are important and the same values I would have thought need to get across those borders.

J

But, whatever we put out to ourselves or the public needs to communicate the.

J

Fact that this is a behaviour,, a value that we endorse in our work with the public.

J

And our work with each other and I, don't know how you do that with a list of.

J

Words without putting something around it.

N

≫≫ Paul? >> Thank, you chairman. I, suppose I looked at these and thought about other instances where I've.

N

Seen values in organisations I've been associated, with,.

N

And my feeling was, these are interesting. Words.

N

Some of them are very fluffy, they're, all quite nice words and there's not much.

N

Which is very challenging, apart from challenge in there,, but I wonder whether.

N

That was right for an organisation that is looking to be investigative and to actually.

N

Hold people to account and is there something more about more hard-edged.

N

Values potentially around scepticism or something like that.

N

I hate to sort of be negative,, but these are all very positive values,. How do we.

N

Drive the right sort of behaviours in our people out of this?.

N

How, do we make sure the public feels and our pay masters feel that we are.

N

Delivering the results behind it as well?.

N

So in another organisation, I have,, we have values which include results.

N

Driven, includes team, working as one team, includes customer orientation or.

N

Customer-Centric behaviours, those sorts of things which are, I appreciate,.

N

They're more businessy orientated, but they have a little bit more around.

N

Performance, about doing stuff, about getting it right,.

N

Which goes a little bit beyond here.

N

I. Don't think you need to necessarily stay with the one word bit for a value,.

N

I think it might be better to drift a bit from pure values into something which.

N

Gets you to what you really want, the organisation to be doing.

N

So I think taking what the organisation has come up with and then translating it.

N

A bit and showing the link between it might be the way to get something.

N

Which you're able to use for the organisation's whole.

N

I, don't think you can have internal values and external,, which aren't expressed externally.

N

I think you actually have to express them externally,. They should be out there, right up. Front.

N

About the way you do, business, that that's what values should be driving.

N

Otherwise, they're not really worth much.

A

≫≫ Anna and then we'll come to you Jonathan.

F

≫≫ I want to agree with a great deal of what's been said, at a risk of adding to.

F

The list I agree with Paul. There's something missing here about being decisive and firm and all the.

F

Things that regulators have to be.

F

But, that's not the primary point,. The primary point for me is just to focus on.

F

The point that Kay started with,, which is the role of the board.

F

Understand, the role of the board in relation to the values not to create them.

F

But to own them, and having owned them to hold the organisation.

F

Accountable for delivering on them in all of its internal and external relationships.,.

F

Camilla's right, there's a question about how much we actually communicate the.

F

Values and how meaningful they are to the general public,, but there's.

F

A really important question about us holding the organisation to account for.

F

Living those in all of their interactions with the public, and I don't feel these are.

F

Anywhere near ready and I would feel very uncomfortable agreeing to.

F

Something being published as the values we want to adopt on the 1st of July,.

F

Without the board, having had the opportunity to know that they are,.

F

They have some resonance with the public, and that's not just our own.

F

Assessment,, but something a bit more than that and that they are things which.

F

We feel we can hold the organisation to account for.

F

So I'm afraid I want to say, there's some more process that has to go around this.

F

And ultimately, before anything is published, it needs to come back to the.

F

Board for us to sign off on them as a tool that we can use for a very important governance, function.

I

≫≫ I'm afraid when I joined the organisation, I wasn't necessarily aware.

I

Of what the previous values were, so on about day, two when I had to get up and.

I

Describe the new hospital inspection, programme, I invented some for the.

I

Time being,, but it was what I personally wanted the inspection programme to be,.

I

Which happened to be robust,, fair,, transparent and when possible, it should.

I

Be helpful, recognising that not all individual providers are going to find.

I

Every judgment we make to their liking.

I

I've used that in public quite a lot and never had any comeback, saying that.

I

It's not in the right area, I'm, not saying it couldn't be improved.

B

≫≫ One point,. We don't want to get into adding lots of values to the list,.

B

But there's one overriding value, which, on the board, we should be more.

B

Conscious of than anybody else,, which is that we are here to act in the public.

B

Interest and although you could interpret some of these values in that way,.

B

That, surely is the most overriding or do I mean fundamental,. That is the value that.

B

Drives everything else and isn't that the one we need to get out more than any other to the public?.

B

That we're acting in the public interest,, so accountability is one word, but it's.

B

Accountability to the public, that we're acting on behalf of the public that drives.

B

All the work and getting that statement out at a time when people are worried.

B

About professional collusion is perhaps the most important part of that.

A

≫≫ I don't think we can just debate words like this,. We've got to see the.

A

Behaviours behind the words and I think the board does need to have a say on that: actually.

A

I think, you know, you'll, go to your executive team next week and you'll.

A

Debate this further, and you'll come up with the behaviours behind the words,.

A

But my feeling is, it needs to come back to the board before we can go stamp on it.

A

Unless, you feel that's not possible now for some reason?.

C

≫≫ Well anything's possible. So. In a sense, if that's the board's wish,, then that's what we'll do.

C

I will respect that judgment.

C

So there's a challenge about how externally facing it, is.

C

That's, a good one, I, don't know how we'd do that, there's a challenge...

C

We've been through a pretty exhaustive exercise over the past three months,, so this isn't something that's not touched. The sides.

C

If we're trying to create ownership, I'm, absolutely with it about. We can finesse.

C

The words and whether the words are right and there's some really good challenges --, but I am with Anna,. I, absolutely understand this point, that it.

C

Is the role of the board to set the values of the organisation and hold it to account.?.

C

I thought we'd been trying to do that by sending these out over the time and.

C

Whether it all needs to be done in a meeting or not, is one of the key issues.

C

With the very best grace, David,. If the board isn't happy with it, then they won't go and we'll have a different conversation with all the managers on the 1st of July.

C

The issue is: we've got 400 managers coming on the 1st of July to have a conversation about values. Now. You could say: I've got this wrong,, in which case I take full responsibility. So.

C

We'll have a different kind of conversation with them.

C

We'll actually tweak that and then it can come back.

C

You must be satisfied as a board that these values represent what you want.

C

To hold me and the executive team to account for and that these are going to.

C

Be embedded in the organisation, and we must be satisfied that they actually.

C

Speak internally and externally.

C

It's not what we were planning,, but if that's a view of the board, then that's.

C

What we'll do and as I say, we'll do that with good grace.

A

≫≫ I think every time,, you know,, the executive team come up with a proposal.

A

We discuss it here and normally, as a result of that discussion, it's got better.

C

A

I didn't mean it to come out quite like that, (laughter), but I think it's improved.

A

Something that was already outstanding has become a little bit more...

I

≫≫ ...going towards the perfect.

A

≫≫ I think it would be better to come. Back, yeah.

A

I think you should narrow these down and develop them,, taking into account it.

A

Must be public facing as well as internal,. It needs a harder edge,.

A

Those kinds of comments. >> It's, a good challenge.

C

David you're absolutely right. Everything that we've brought here you've added value to and I, don't think.

C

We should actually draw a different line around this one.

C

The plan was on a different trajectory,, but if the plan needs to be revised,.

C

The plan needs to be revised and that's what we'll do.

C

So I don't think. We should turn this into a big issue,. We just need to rethink what we do on the...

A

≫≫ The board is saying this is an important issue,. This is an important thing and we need to have another discussion about it.

E

≫≫ I wouldn't want to lose the rest of the organisation's views. Either.

E

You know, obviously, we set the values, but there has been a whole process and.

E

Things have come out of it and that does need to be very influential to whatever.

E

The final values are.

A

≫≫ I agree.

C

≫≫ We'll bring that back to the next meeting, because I think we need to.

C

Maximize the momentum that we've got so, let's take the report,. Let's go to the.

C

Conference and then, let's bring it back.

C

I. Think 18th of July is our next meeting? >> 13th.

C

≫≫ 13th. Okay well we'll bring it back to that. Meeting.

A

≫≫ Jonathan thanks very much,. Sorry to put a temporary spoke in the progress.

A

Tracy, did you have any other issues on HR? You wanted to highlight?.

M

≫≫ Not, unless anybody's got any comments on the remainder of the report in respect of the survey results and the Sarah Hunter work?.

A

≫≫ Okay, Jennifer?.

D

≫≫ Thanks so much for the survey,, which looks very useful.

D

Just two things, one is the slide, which shows that the level of people who.

D

Would like to improve certain areas and there's one area which is sort of.

D

Outstanding,, which is the fact about effective systems and processes, to enable my work.

D

It wasn't so much workload,, it was more effective systems,. So that's one point,.

D

And then the second issue that jumped out to me was the slightly lower results.

D

Across the board, in a number of questions from the National Consumer.

D

Service, Centre and I wondered what was happening there and whether you could say more?.

L

≫≫ I'll take the issues of systems and processes and I'm sure Tracy can follow.

L

Up with the NCSC.

L

Systems and processes, we're fully aware that our systems and processes.

L

Are not in good order, not wholly in good order, Jennifer.

L

They have been designed to do other things and we've changed most of what.

L

We do, so the systems and processes need to follow the redesign of inspection.

L

Methodologies, and that involves a lot of unpicking and rethinking.

L

We are also very conscious. We need to make investments in our infrastructure,.

L

Particularly our IT infrastructure, and that is happening.

L

One of the really encouraging things that I was talking about yesterday was.

L

Some fundamental redesign of our IT systems and the redesign is being taken.

L

From the perspective of somebody who was not office based and that's actually.

L

A very important perspective to take as we move to an organisation which will.

L

Be close to two-thirds of people who are working office independent.

L

So we need them when they are mobile and at home to be able to work.

L

Effectively and productively, and our systems to date have not supported that.

L

So we're making great investment and actually unpicking;, we've so far found.

L

300 inhibitors to efficient and productive work and we are unpicking those and.

L

Rebuilding from the basis of the perspective of the person who has to do the work.

L

That's just one example,, but we have many, where actually the internal wiring.

L

Needs to be completely unpicked and put together in some instances to make.

L

It more efficient, make people feel they are supported in doing their work and to.

L

Allow us to be productive, because that is fundamentally what we need to do and.

L

What all of our colleagues want to do, is to be able to do their jobs and do them.

L

Productively and do them well, and it's not going to be an instant fix, is what I.

L

Would say, because it's a very big undertaking.

L

>> Messaging is being clearly communicated to staff,.

D

That could help with morale, couldn't it? That. This is a journey, and although one.

D

Of our values at the moment is effectiveness, we're not there yet,.

D

And this is going to take X number of months.

L

≫≫ We take every route that we can think of to communicate. The fact that we.

L

A, recognise things, aren't good and B,. We are putting in place what I call fixes.

L

And patches to get us through, but also that we're doing a whole bigger system.

L

Rethink of how we work,, where we work and the tools that we make available to.

L

People to do that and trying to get that message out and it's a hard message.

L

When people are working incredibly hard and getting frustrated with some of.

L

The systems and processes. To be able to say the fixes only get you so far,. The rethink is going to take,.

L

You know in some cases the lead time would be 12 to 18 months and beyond,.

L

And that's a hard,, hard message,, but the journey has begun to get this right.

L

And we'll continue to message hard on it.

L

The NCSC, I'll pass over to Tracy in terms of things that we are doing.

L

I think one of the things I would preface this commentary by is by saying the.

L

Ncsc; for colleagues who don't know what it does,, it's a 350 seat contact.

L

Centre principally,, but does an awful lot of our front facing customer work,.

L

In terms of those that come to us with concerns, complaints,, safeguarding issues.

L

It does a lot of document management, a lot of business support into the organisation.

L

Supports on the inspection, planning. So, it's a very busy area of activity for CQC and we recruit in Newcastle an.

L

Incredibly, talented workforce into that area and one of the benefits for the.

L

Organisation of that -- I think it's important to give some context,.

L

Has been that that very talented work force often migrates into the other parts.

L

Of CQC, we scoop the talent out and bring new talent in,. So it's very ambitious.

L

Very dynamic area, and actually, unlike many contact centre environments, you.

L

Will find, because of the way the CQC are set up and the location in Newcastle,.

L

So we're very lucky to have it and it is a core fundamental plank of the work. The CQC does.

L

Notwithstanding, all of that we have some very stubborn issues within NCSC.

L

Some of which Jonathan and Tracy will talk. About, are not unusual in a contact.

L

Centre: environment and it's not to excuse them,, but which we are working.

L

Very hard to identify, root cause and then to work through how we can actually.

L

Make the changes which are very visible and I think that's quite important in that.

L

Environment, visible and visibly understood that we are taking these concerns. Seriously.

L

I'll pass over to Tracy,, who can just talk about some of the particulars there.

M

≫≫ Thank you. Just on the issue around systems and processes before we move on,.

M

I think one of the important things about that is you know. People's reality is what.

M

Matters, so I think when people are answering the questions in the survey.

M

And we're going to be doing the next survey in July, and if you couldn't get on.

M

The system the day before to upload something,, that's the thing that sets.

M

Your view about how you want --, so you know, I, think some of these things.

M

People reflect on a lot more,, but the reality of people's working experience is.

M

All important around that issue and that's the feedback we're getting about that question.

M

So there is a lot of plans in place, but that will still be a difficult area,.

M

Until people's reality, changes.

M

I think in respect of the NCSC, people have visited the NCSC,.

M

It's a very different working environment to the rest of the organisation.

M

It's not gone through the type of change that the rest of the organisation,.

M

But it's heard about it and I think that's part of what's being going on for.

M

Them is they've, seen the organisation changing and shifting and the message.

M

Is how is this going to impact on us and it is impacting on them greatly.

M

Some of the concerns -- the NCSC,- it's grown in such a short period of time.

M

From nothing to this, you know, big operation and I think some of the ways.

M

Of working, staff are very engaged in that.

M

It's a call centre, but an incredibly engaged group of staff who care.

M

Passionately about what they do and therefore engage about the way in which they're managed.

M

So some of the issues that staff have raised. We are addressing.

M

One of the big concerns is there's a great turnover of staff, both coming into.

M

The NCSC and moving out into the rest of the organisation, because they are a.

M

Considerable talent pool as Eileen said.

M

The NCSC management are moving from having a lot temps to making a lot.

M

Of those permanent and changing the models, they're having a much more.

M

80 percent permanent workforce and 20 percent temps.

M

So the opportunity to do that,, which will be happening in the next few weeks,.

M

Is a big opportunity for us to say we're going to do this in a different way,.

M

A way that reflects some of the values issues that we've discussed, much more.

M

Transparent because there are concerns, there's a lot of favouritism, nepotism,.

M

That people are picked for projects and those projects lead to better jobs.

M

Now in order to demonstrate that isn't the case,, because we don't believe it is,.

M

But we are going to work on how we do the recruitment and selecting people.

M

For opportunities in a different and transparent way in order to, as I say,.

M

To be able to demonstrate to staff and challenge some of the assumptions,.

M

Even if we don't agree with them,, if those are the beliefs that people have,.

M

We need to work with them. So. Those are some of the things that we're going to be doing and lots of work.

M

Around communication and engagement of individuals in groups within there.

M

Another area that's caused concern. There is around how performance is.

M

Managed and people being concerned about appraisal and performance review.

M

Again one of the conversations we're having is, because it is a large group.

M

With lot of team leaders and line, managers, is actually looking to have.

M

Fewer performance managers, but having those being much more skilled at having.

M

Those performance conversations, so having lots of people who manage the.

M

Work, as a team leader,, but actually making performance, something which is.

M

Done really, really well by investing in fewer people having those performance review, conversations.

M

Those are all things that we think will relate and respond directly to the.

M

Concerns that staff have expressed and also demonstrate that we are listening.

M

And doing things differently as a result.

D

≫≫ That's good to hear. It's been guide a duel. This centre hasn't it, the morale,, the energy level and so on.

D

Just to see those figures, just to keep it on the top of our mind, I guess.

A

≫≫ Thank you Jennifer. Any other questions?.

A

E

≫≫ It's about the culture and the workload.

E

We know that staff are working extremely hard and in fact, I think.

E

They're actually being hugely heroic actually, and we shouldn't underestimate that.

E

They're doing a -- really dedicated and working really hard, so I guess in terms.

E

Of the culture, I think we need to be careful that doesn't become the norm.

E

We want people to work hard and be dedicated, but some of the hours people.

E

Are working are really quite long., So I would hope, as we recruit and change, I'd expect. That would change,.

E

You know, because I don't think it's sustainable and I'd be looking really.

E

Quite hard that that is being addressed.

E

Alongside that, I'd be particularly interested in what we do around staff well-being.

E

I know things are happening, but I think we need to as well as sort of support.

E

And listen to our staff,, but look after them as well. A bit.

E

So in time, I'd be quite interested to know a bit more about what we could do around that.

E

Finally the last issue: which,, it is an operational issue,, but I will raise it.

E

Anyway, is that I'm being told that staff are doing lots of overtime, but they don't.

E

Know if they're going to be paid for their overtime and they're saying we can't.

E

Take time in lieu because there's too much to do.

E

So I'd just like to sort of understand because I think it is a morale;.

E

We've got people working really hard and are being heroic and.

E

Then, to be told they might not get overtime, pay and I would just like to.

E

Understand that a bit and to see, you know, will it be resolved because I think.

E

It is impacting on people.

L

≫≫ I'm sure that Tracy and indeed David, might have some views on this.

L

First of all to go to our duty of care and the well-being of staff,, it's very important.

L

To us- and we do know that we're asking a lot of them.

L

A lot is being asked of everybody across the organisation.

L

We do all the usual things that you expect a good employer to do and we do.

L

Encourage people to make us aware when they feel things are becoming too much.

L

We are, as David said, in his opening statement to go to workload and how.

L

We're dealing with it,, we know that in some areas of the organisation,- and it is.

L

Not universal,, it's across all areas,. We do have teams that are understaffed.

L

And, we do now have a pipeline of new colleagues joining us,, so over the next.

L

Few months that we hope will tail off,, it won't tail off completely, and as we go.

L

Into 2015/2016 we will still be recruiting staff to get us to 100 percent of the.

L

Inspection commitment that we've made.

L

So again as I was talking about systems and processes,. This issue of work and.

L

Momentum is going to be with us for some, while before we get to what you.

L

Call might call steady state. Now,, we have said to staff very clearly a few things.

L

First of all, we have a bank of staff colleagues who have been with us for.

L

Some while and we have asked them if they can actually do more work for us.

L

So, we have invited them to tell us whether they will work out of traditional.

L

Geographies that they've been in, and are willing to do more hours than they might usually do.

L

We've also said quite clearly to colleagues in most areas, that toil is still.

L

Possible to have and actually we're telling managers to make that clear.

L

There are only one or two areas in the organisation where it should be.

L

Impossible currently for toil to be executed, and they have told managers.

L

That that is the case and are encouraging staff to take it.

L

Overtime, in principle, is not a good thing from a duty of care perspective to an.

L

Employee- and that is our fundamental concern at the moment.

L

So I'll marry that with the other concern which I know that boringly, and colleagues are very bored with me on this subject,. We also have to be very sure that we can afford it.

L

We're not seeking to exploit people,. We need to look after them and we need to.

L

Make sure we are exercising prudence in all of our resources before we make.

L

Decisions around overtime, there are one or two areas. We are looking actively.

L

To see whether it's possible,, but actually it is not a good thing to do,, so we're.

L

Trying all other routes and remedies before we get there, Kay, I, hope you'd.

L

Agree with me that that's the right thing to do.

A

≫≫ Any other questions for Eileen and Tracy or Jonathan?.

A

Good,, thank you very much.. Thanks Eileen, thanks Tracy.

H

≫≫ So: this is an update to how we're considering reviews, what we previous.

H

Discussed as appeals against ratings.

H

It follows the March public board paper and discussion that we had.

H

If I sort of pick out the highlights from the paper to say we haven't had a formal.

H

Approach for a review,, we think that's in large part down to the fact that we are.

H

Being as open as possible and engaging in as good a dialogue as possible with.

H

Providers as we go through the process.

H

There are a number of stages before we'd get to any sort of formal review. As.

H

We've set out previously and in this paper.

H

We think a review should only take place at the point at which the inspection report is published,. That gives plenty of opportunity through factual accuracy.

H

For example,, but also through the ongoing dialogue, as we confirm the.

H

Ratings for providers to raise concerns with us and, of course, we're open and.

H

We talk to them about that,. Mike can give us a view on how it's going in the acute sector.

H

Also committed to doing this transparently through the board meetings and making sure the public are aware of the way we're considering this.

H

What the paper is seeking to do is provide an update on the thinking,.

H

We seen this as a process of thinking as we move towards October and the.

H

Regulations under the Care Act and the Care Act itself being something we can.

H

Fully go for,, including new rules and regulations around ratings, themselves.

H

But, one of the things that we've developed or thought through has been.

H

What do we actually mean by review, and we think it should be much more a.

H

Process than a specific event of a formalised hearing.

H

One of the previous conversations we've had is: would the person.

H

Requesting the review or body then attend a hearing?.

H

I think the point from our perspective is,, the hearing isn't the thing,.

H

The thing is the process of reviewing the documentation,, given that the review.

H

Itself would largely be on whether the process of getting to ratings and.

H

Aggregating them was the right one rather than elements of factual accuracy.

H

Or disagreements with our methodology, which are kind of covered through other processes.

H

All of the other things that the paper is trying to highlight is that we think it's.

H

Important that there's consistency in the approach to reviews across all the.

H

Different sectors that we regulate.

H

As in a number of things,, the Acute sector, is one where we've started a little.

H

Bit earlier,, so two consequences.

H

One is that as we roll out across all sectors,, we need to make sure that.

H

Anything we're doing in the Acute sector isn't going to disadvantage or be difficult.

H

For another sector and going backwards, we then might need to change the.

H

Approach that we take in the Acute sector, as we learn about how these things in the other sectors... Just a sense of the realities of driving a consistency, agenda.

H

The board's being asked to do two things, one is, if you turn to page six.

H

Of the paper, there's a series of proposals,, some of which are quite.

H

Operational, but we want to give you the full detail of what we're planning on doing.

H

I would say the one is look at is bullet point 3, where we make that point.

H

About it not being inevitable that reviews would have a formal hearing and seeing.

H

Them more as a process, rather than an event.

H

Possibly, to reflect on this point about consistency and also in appendix one.

H

Just to look at the job description that we are suggesting for the independent reviewer.

H

Suggesting two independent reviewers in the fist, instance.

H

From, the previous discussion, who did want to see the organisation's current or.

H

Previous values, they're, expressed as the competencies on the last page or two.

D

≫≫ Just a quick question,. Last time we discussed this,, you quoted a salary range for the independent reviewers that I thought was too high, because I didn't.

D

Think we needed QCs necessarily to be doing this job,. Are you going to be telling.

D

The head hunters, something slightly lower?.

H

≫≫ Significantly lower. We always want to put that in as the absolute top of ever.

H

We weren't in the situation where we were going back to the board and saying well, actually thought it was a bit higher.

H

I think the number was 1,000 to 2,000 a day.

H

I, don't think we need to be on that high,, full stop.

D

≫≫ You can assure us we will not be paying the top level?.

H

≫≫ Can I say: let us go through the head hunter process to see. If we can get the right people at significantly below that level.

H

If, we find we can't get the people of the calibre we want. Then we'll have to come.

H

Back, but our intention is not to have to pay those rates.

D

≫≫ ...recently,, but the transparency with which we compile a rating, is that.

D

Granular enough at the moment, in order to be able, to, I guess, head off or reduce.

D

The number of challenges?.

H

≫≫ So it's set out in the provider handbooks for consultation,.

H

The consultation closed just a week ago from memory,, so we're collecting the.

H

Responses on that,, but it was set out in quite some detail, then, following the board discussions over all those aggregation, principles.

H

So we'll see what people said as to whether they feel it was clear enough.

H

But it's all those points about (inaudible) requires improvements.

I

≫≫ Paul mentioned I can say something about what's actually happening in practice on this.

I

Board members will remember that in wave one we shadow rated three of the.

I

18 Trusts and then published those together with the wave one report and.

I

For each of those shadow Trusts,, we offered them a conversation, mainly by.

I

Phone about the ratings and I think they found that helpful and largely this is.

I

Talking them through why we have come to a decision that something either.

I

Requires improvement or is inadequate. Surprisingly they're not worried when it's good or outstanding.

I

In wave two we've continued that where necessary, so a number of chief.

I

Executives have asked about particular ratings and I've offered them a phone.

I

Call and so far that's always resolved the issues.

G

≫≫ Sorry, just to say, I think that that's brilliant but we're 25,000 locations.

G

For adult social care., I think the point Paul has made around trying to ensure some consistency.

G

Across the piece,, we do have to be careful about the expectations that, as.

G

Much as I would love to have a conversation with everybody about each.

G

One of -- I am physically not going to be able to do that,, so we're going to.

G

Have to think about how we do handle this in an appropriate and proportionate.

G

Way for the different sizes of our sectors that we're regulating.

I

≫≫ I'm not even saying it should always necessarily be me within the hospitals. Directorate, I would hope that my DCIs and others will have those.

I

Conversations too, up until now, it happens to have been me.

A

≫≫ Jennifer, just one more... >> Just, the processes by which we.

D

Check consistency of our judgments against agreed, facts.

D

So, where the facts aren't in dispute, but there may be consistency issues in the.

D

Judgment of those facts, despite the granularity of the handbook.

D

Do we have an ongoing process of assessing that?.

H

≫≫ Shall I start with that, Mike?

H

I. Think there's three prongs to it.

H

So there's the work that Mike does and spends a great deal of time with his.

H

Dcis and others on the quality assurance groups, so to make.

H

Absolutely sure, as we go through what the inspectors think, the answer should.

H

Be, rating by rating, that that's consistent, as people who see multiple different providers.

H

Secondly the route that we're developing on the wider assurance of that process,.

H

Which goes through to the regulatory government and values committee that Michael chairs, led by Louise, Donnelly and others, and the third piece is the.

H

Valuation work that Ciaran Walsh has been doing to inform us on the area,.

H

As much as I think the risks to the process to make sure that we've got.

H

Them covered, and I think there's a report coming back next month to the.

H

Board on his final report.

H

Yes, it is, yes.

G

≫≫ Can I just --, because I think it is really interesting to see how we apply.

G

This across into the broader areas and I think it does start with as being much.

G

Clearer than we have been around the characteristics of what a good and.

G

Outstanding service is and what an inadequate or a requires improvement.

G

Service is, so that actually Paul's absolutely right,. The kind of assurance.

G

That we need to have,, but we need to be starting it right from the beginning. In.

G

Terms of how we're equipping our inspectors to know what good looks like,.

G

To be able to collect the evidence through the intelligent monitoring and.

G

Through the inspection teamwork to get to the ratings,, so that there's a.

G

Transparency in terms of the information that goes into the report,, which can then.

G

Link across to those characteristics so that people can see that right at the outset.

G

The approach around reviewing that, ensuring that there's an assurance.

G

Around that will happen in each of the directorates,, although obviously in.

G

Slightly different ways, given the volumes in the three directorates that we've got.

I

≫≫ I think this is probably, as we've said, before, the biggest challenge is consistency.

I

The way we are approaching, it absolutely is to try and define what good.

I

Looks like and be as clear as possible about that and I think we've made major steps: forward.

I

Our second step is then in training our inspection team, so they really know that.

I

And they understand that and we're going to have a big blitz on that over the.

I

Summer, particularly related to our eight core services in the Acute hospitals.

I

Making sure that people do know what we're looking for and know how we.

I

Are rating them,, but part of this is it's now that we've done around 50 national.

I

Quality assurance group meetings for the different Trusts, we've actually seen.

I

Where the problems may lie and the things that we need to be consistent, about.

I

There are things that frankly, I hadn't thought about at the outset,.

I

But which are clearly important that we should be consistent, about.

I

To give an example, in outpatient clinics. It sometimes happens. That notes are not.

I

Available, that can both impact on patient safety. If you don't know, what's.

I

Been going on in the past,, it can impact on patients being delayed while.

I

Information is found about them from other sources,, so it can be part in effect, responsiveness as well.

I

But, we didn't know where the bars were in the NHS and we're getting to the point.

I

Where we've seen enough information coming through to say this is where.

I

We'd put inadequate for that particular rating,, but that's something we hadn't.

I

Thought of from the outset- and there are multiple examples like that.

D

≫≫ Just one last thing,, the obvious point that time and experience is going to.

D

Increase consistency of judgment.

G

So there's a real issue of keeping a gimlet eye on the churn through our.

D

Inspection teams and to try to come to agreement about what is an appropriate.

D

Proportion of people that we're really aiming for that's consistent, each time, in each team?.

I

≫≫ Just in response to that,. By now having the DCIs taking on the chairing.

I

Role quite frequently in our inspections,, not exclusively,, we still have a lot of very.

I

Able outsiders doing that,, having almost all of our inspections now being led by.

I

A head of hospital inspection and they've all done six,, eight or ten between.

I

Them each,, so we're really getting to a point where we are getting more of.

I

That consistency, and now it's down at the inspector level, that we need it as well.

A

≫≫ Paul that okay, happy with that?.

H

≫≫ If people are content with the bullets and so forth.

A

≫≫ Michael Myer would have presented the next item,, but he's not here today,.

A

So Eileen you're going to do that. Instead,, I think.

L

≫≫ I'll try to do a good impression of Michael for you, but I'm sure I'm, going to fail.

A

≫≫ Long pause, !.

L

≫≫ As I said I'm sure I'm going to fail.

L

I spoke to Michael about the report, he's content that it's accurate, it stands,.

L

It highlights areas where we know we need to improve, areas where the.

L

Audit and corporate governance committee has picked up the mantle,.

L

Picked up the bit and where we look forward to Paul, actually helping us to.

L

Drive much greater improvement in the coming year.

L

I think it does also highlight where the CQC is taking these issues around risk,.

L

Issues around process and assurance of what we're doing, very seriously and.

L

Investing a significant amounts of management, time and effort in trying to,.

L

We're not quite at the point of embedding, because we're still building what good.

L

Processes looks like and then there's a process of education, then we'll move.

L

Towards embedding,, so a little like the answer, I gave to Jennifer about how.

L

Quick is the fix, I, don't think it's instant,, but I think the awareness of the.

L

Importance of, what's being noted here, has grown very significantly in the last year.

L

The activity around it has certainly built an incapability, and in the next year, I.

L

Would hope that when Paul will present this report next year, that we'll be in a different place.

L

But I will try to take questions,. I won't answer them with anything like the.

L

Clinical precision that Michael does but I'll do my very best.

A

≫≫ Camilla. >>, Thanks Eileen.

D

Given the very serious issues that this report raises,. Should we not have a.

D

Report to the next board meeting, rather than waiting till next year?.

A

≫≫ I suppose, where I am on this, I was waiting for Paul Ruse,. The new.

A

Chairman of the audit committee to spend a month or two to review where.

A

We are and ask him to provide us a report, probably in September.

D

≫≫ Okay. >> Do, you feel that's okay?, >>, Yeah, I, think it's a very good report. It doesn't pull its punches,. It's very clear, that he can't give us the assurance. We should expect, and we kind of all knew that. But when you see it written down on.

D

A piece of paper it's slightly alarming!.

A

≫≫ I have felt for a long time that the audit committee was not up to scratch, is putting it kindly.

A

And Paul I think I made it clear to you when you were applying for this job,.

A

You weren't taking over a well oiled machine, so I'm really hoping that Paul.

A

Will look at this in great detail over the next couple of months.

A

Have you any sort of early reflections?.

N

≫≫ I'm puzzled, is probably where I put it, I, don't take quite the same degree of.

N

Panic about it,, if you like,, as could be read into it.

N

We regret that we were unable to give the board the level of assurance that we.

N

Would like, which we believe the board should be able to expect, and then.

N

Across the audit programme, internal audit was not able to offer full assurance.

N

In any of the areas reviewed. Substantial assurance was offered in four areas, partial assurance in ten and limited in one.

N

I'm not quite sure what those ratings mean in this context and I think this.

N

Afternoon we've got the governance report which we're looking at as well, a draft of that.

N

I wasn't entirely sure what it meant., >> Right, yeah.

N

≫≫ I have seen other places where you certainly don't get full assurance on.

N

Everything by any means.

D

≫≫ I think we're an organisation in transition, and we know that creates a lot.

D

Of risks,, so I agree.

N

≫≫ To answer your question: how current these audits were because if they were.

N

Done early in the year, then maybe things have moved on since then, as well.

N

So I'm puzzled at the moment.

N

I'm, certainly not going to take away from what Michael said: here, you'd, obviously.

N

Like to see better report- and that surely has to be- where we're going over the.

N

Next year, or so in terms of getting better assurance around things,.

N

But I don't quite know how difficult it is. >> Could I ask one question?.

A

≫≫ I wonder Camilla that we ought to have this discussion when Michael Myer is here as well.

A

Can we park this for a month?.

D

≫≫ Could I ask one question, I'm sorry I've asked this before, and I still feel puzzled.

D

Can I just understand to what extent the audit committee is responsible for.

D

Assuring the board of the financial management of the organisation?.

D

I'm still not clear on that.

N

≫≫ It's, certainly one of the areas. The audit committee should be looking at,.

N

In terms of the adequacy of the processes and the systems and the.

N

Management of the finances of the organisation, yes.

D

≫≫ Good. That's, the first time I've felt: we've had -- okay, good.

A

≫≫ I, don't like seeing a paragraph saying we're unable to give the board assurance of stuff.

A

If, you can't give us that assurance. That is a serious issue.

A

I think a layman reading this would read it.

N

≫≫ I think it also depends on what the areas that we can't give assurance. Are,.

N

Because if it was, they can't give us assurance over the finances in the.

N

Sense of the accounts then we'd be in trouble,, but if the accounts are getting.

N

Audited and there's a clear opinion on that,, okay, it's not that particular area.

N

It may be around all sorts of other areas of assurance about management,.

N

Processes and so on, internally,, which is an important area, but a different one.

L

≫≫ So, what I think it's useful to say is that the basis upon which Michael.

L

Appropriately made his statement was on the basis of an internal audit plan,.

L

Which was legacy and historic and didn't and doesn't reflect quite a lot of what has gone on since.

L

It does not mean that we would have substantial assurance across everything.

L

That we do in the organisation at the moment, because that's not true,.

L

But if we look at the two year forward, look around what we are going to have.

L

Internal audit look at,. It is a very proactive,, very well managed,.

L

Very well structured set of activities.

L

So when Michael and I discussed this,. He was quite keen of reminding.

L

Ourselves that we were using the lens of legacy- and it wasn't fully reflected of.

L

Where we are,, albeit we know that we've probably gained new risks, as others have diminished.

L

The financial side of life is that the audit committee properly will make sure the.

L

Systems and processes are in place,. You will look to ET and senior colleagues to.

L

Make sure that actually, the spending is appropriate, and that is what we'd report here to the board.

L

The audit committee will, in summation at the end of the year,, ensure that the.

L

Annual report and the accounts are appropriate and that your auditing and.

L

Assurance processes around those have been completed, and that is the function of audit.

L

So I don't want to go on, but I think Michael was quite keen when I spoke to.

L

Him to remind me when I was saying, oh dear, this doesn't read very well. Does it?.

L

To absolutely remind that quite a lot of this is the lens of the past and what we.

L

Need to be very careful, and mindful of is that the lens of the present and the.

L

Future are probably as important now. >> Camilla.

D

≫≫ I think you've very helpfully put your finger on something there, which is what I think bothers me.

D

I've always expected that the audit committee of this board should look at.

D

Spending as well, not just sign off on year-to-date, have we spent the money.

D

That we've got in the budget, but also how wisely have we spent that money?.

D

We just need some kind of independent view of that,, don't we?.

L

≫≫ It would be unusual for an audit committee to do that, Camilla.

D

≫≫ Not on other organisations that I've sat on it's not.

A

≫≫ We're doing a lot of work on whether or not we're getting value for what we.

A

Spend, value added work is that what you're talking about?.

D

≫≫ Value for money, yeah.

A

≫≫ I've talked to Paul Roux about a lot,. That is a very important part, yeah.

L

≫≫ Indeed our auditors and our NAO colleagues, one of the challenges that.

L

They bring is about value for money and the processes around which we buy things.

L

That's, not a monthly run-rate analysis of spending, but it is about processes,.

L

Value for money, are you using all best avenues to operate? Commercially,, I, suppose.

L

So, that's a challenge that they bring and which, increasingly internally we're.

L

Deploying also Camilla, I hope, that's helpful.,.

D

≫≫ I'm so sorry to prolong this,. How does that connect in?.

D

You're getting advice from those people,: how does that connect in to the board?.

L

≫≫ The way it connects in via the audit committee is that they will give opinions.

L

On activities that we undertake,, that connects into the reporting that that.

L

Committee makes to here, which is the governance line, that we have.

D

≫≫ So, the next time we're asked to sign off on a large amount of money for.

D

Something,, this is where it comes home to the board, because in the past we haven't had an ideal process for this,. We will have obviously your advice.

D

Hopefully- and we will have the audit committee or Paul will also have some.

D

Sort of detailed view of whether we should spend the money and that's.

D

Really, what I'm talking about.

N

≫≫ I think I, see where you're going now.

N

What you would normally expect to see is that there is, first of all, there's a.

N

Process for making sure that when you buy something, you commit to buying.

N

Something that that's not appropriate and the right assessment is done of what you expect to get out of it and you're paying the right amount for that..

N

What would then happen once it's been spent and done,. If you like, there would.

N

Be some sort of review of the post implementation review of? Did we get.

N

What we expected, did we get the value out of it that we wanted, and that would.

N

Be something that would be normally be done by management.

N

A post project review is a normal piece of work, and that is something done by.

N

Management and the reports on that should come through the committee and.

N

The board,, not just the audit committee in that respect.

N

So, where there are specific bits of unusual expenditure, I think that would.

N

Be an appropriate route to take.

A

≫≫ Just remind me of the limits that need to come to the board for spend?.

L

≫≫ A million pounds and above need to come to the board.

A

≫≫ Can, we come back to this?

A

A

≫≫ No, no you're, expressing a nervousness that we all have I think in this area.

A

Can we come back for a more structured discussion about this in.

A

September, when Michael Myer is here as well, but when, Paul, you've had a.

A

Chance to sort of see what the audit committee has been up, to.

A

Can we park it to September Camilla?.

D

≫≫ It's, not that I don't have faith in Eileen to make all these...

D

You're, absolutely on this value for money, thing, and I know you are, I'm, not saying anything about the organisation, I. Just think that we are.

D

Accountable to taxpayers- and we need to be a little bit clearer about the way we do that.

G

≫≫ Can I just say it isn't just Eileen,. It's all of us who have operational.

G

Responsibility and budget accountability for the way that we spend money.

G

I've got a budget of many millions and 800 staff and all of the rest of it and.

G

Actually, through the board performance reports and the finance management.

G

Reports- that is the other mechanism by which the board holds those of us with.

G

Operational responsibility to deliver on this accountable for what we do,.

G

And so I think it's kind of part and parcel of the same thing.

G

So not to kind of undermine what you're saying Camilla but I. Think it's not just a.

G

Responsibility of the person who's got finance in their title,. It's actually the.

G

Responsibility of all of us who are strategic and operational.

A

≫≫ Thanks, part of the nervousness is, we have not had good management accounts, either.

A

That's been the problem, we haven't, had good management accounts for the board, either.

A

But we will do from next month, so that's...

A

When, we have a combination of good management accounts and we have an.

A

Audit committee, in which we can trust, I, think a lot of our nervousness will go away.

G

≫≫ If I may...

G

≫≫ If I may. What would be helpful when we come back to this in September is to.

G

Actually see how these two things interact with each other, rather than what.

G

The audit committee does but how we transparently and effectively manage.

G

Our resources, through the management line, as well as through the audit and assurance line.

A

≫≫ We will see the new management accounts in the next meeting. So that's the first part of the jigsaw.

A

Right,. Thank you for that.

A

Any other business from the board?.

A

Bren you've sat through very patiently the last few hours after got on your.

A

Bus at 4.20 this morning, is there anything you'd like to ask?.

O

≫≫ That wasn't a luxury that one really,, but that was a worded commitment and.

O

You must stand by that as we set.

O

When you say: I can't make that board meeting I'll try and make the next.

O

One, we stand by our word.

O

I wrote down a couple of things, really as the board conversations took place.

O

I'll go there briefly, really, about the conversation around safety and complaints.

O

When I took the booklets from your rack outside,, the other aspect,, and it's right.

O

Behind you is the quality aspect, as well, is again making sure that the quality.

O

Aspect of that runs right through it in terms of safety, as well as the complaints.

O

So just jot that one down, Mike's comment around consistency came up.

O

And, to be honest, if we're looking at high support and high challenge, I think that.

O

Might come up at board meetings again and whatever really,, because I think it's.

O

So crucial that aspect of consistency all the way through.

O

David, you mentioned a bit about the lay person and that really, looking at that.

O

Assurance and whatever, really and I think it's about really understanding that.

O

Really,, what does that actually mean?

O

On a day-to-day basis, a lady called Jan in Kingfisher, locally for me,.

O

Always reminds me very, very clearly: what does that actually mean,.

O

What do these words really mean at a grassroots level, with people and the.

O

Most vulnerable people we're serving really and in terms of the assurance.

O

Really, we talked a lot about process and that's really important, but I wrote.

O

The word outcome down there as well.

O

I think Kay's point really which she used or word that she used in terms of.

O

The discussion on behaviour around choose, and I look at public health.

O

England's website and see what Duncan Selby has put up there and what he puts.

O

Out in his Friday messages.

O

People in organisations choose to behave,, not how they behave,.

O

How those individuals choose to behave on a day to day minute by minute, basis,.

O

Both internally with one another, and externally, really and I think he's put.

O

Some really good stuff on his PHE website around behaviours and what the.

O

Behaviours actually mean really and some of the detail behind them.

O

Sorry to come back, Camilla,, really the outward facing aspect of it,. What does.

O

That really mean for people,, so we have the high level discussions around the.

O

Board today,: what does that really mean when it filters down?.

O

If I may, I'd just like to offer an example of why you've got some very.

O

Tremendous staff, who I've heard are working pretty much flat, out,.

O

I just want to pay credit to Sue Macmillan who works in Steve's.

O

Directorate and I want to highlight why that is.

O

Two reasons really, is hopefully what -- we're going to, hopefully support locally.

O

Really is how we look at those wrap around services,. The life course model.

O

Being led at a community level really and what that really means for big national.

O

Organisations and I dropped Sue, an email to say, that's the approach to it.

O

And, something came back to say: well, actually, would you like to come and.

O

Sit on the advisory group for the GPs,. Why we're looking to inspect children.

O

And babies, et cetera,, really, and I'm a real, real, keen believer. How do we make.

O

That national bit, really connect at a community and neighbourhood level?.

O

That's credit to Sue Macmillan, tons of stuff on but actually saw the vision behind that really.

O

The other aspect, I'll finish with really, I co-chair the CQC's equality voices.

O

Group and we've decided in terms of our work plan, we're going to look at sectors.

O

One of the sectors that I've opted for is the GP and primary care and whatever really.

O

The vision of the person saying we need to have a look at that,. Would you actually.

O

Like to come and be part of a session, we're running.

O

That's about the person seeing it,, that's about the person,, the vision,, that's about.

O

How do we actually connect that so just those few points, if you like.

A

≫≫ Well, thank you very much.. I must say when ones having a dark day in the office to get a cheery email of.

A

Support from you is hugely appreciated and you're. A constant reminder that we.

A

Can sit --, there's a risk that we sit in an ivory tower here and we must always.

A

Look at how things play out on the ground.

A

So I think I could certainly speak for most of my colleagues here who you're.

A

In communication with just say how much we appreciate your words of.

A

Encouragement and support and I hope you'll join us for a sandwich and a cup of coffee now Bren.

O

≫≫ I will David. I, wasn't -- sorry, I wasn't being rude -- because I've read the papers and fed.

O

Back to people that was the plan B at 4.25 had I missed the coach,.

O

So there was always a plan B and whatever really.

O

I was listening, but I wasn't turned on. Everyone is because a small little.

O

Community group are actually looking now. How do we really connect that work.

O

At a cabinet, office and I was just going through what they're putting in in their.

O

Proposals for that.

O

They're, not people that have done the funding treadmill for 20 odd years or.

O

Whatever, they've just stayed very low behind the radar, and day after day after.

O

Day have delivered to some of the vulnerable people that we've talked.

O

About,, so that was just an apology to say: I wasn't being rude,, but that's got to.

O

Go in quite quickly and I need to support it,. But thank you for allowing me to speak.

A

≫≫ Give our kind regards to Jan as well?.

F

≫≫ Not on Ben's contribution, for which thanks also, but point of process,, we've.

F

Got a board forward plan which takes us to the next meeting and I would really.

F

Appreciate -- we've got a really clear work plan for the year,. We know what.

F

The big things are that we'll need to have an airing both at board workshops and.

F

At board meetings and I know there are things that we have said. We will have.

F

Papers on at the board, which still aren't on this list even for July.

F

The one that we rehearsed were we going to do in May,. Were we going to do.

F

In June, and you weren't here in May and I, wasn't here in June, and now it's.

F

Not on the list at all,, so I worry that we're not capturing the things.

F

That we said we want to talk about, and that we don't have a clear sense of the.

F

Things we need to talk about so I'd, just really like to ask for a forward plan.

F

For board workshops and public meetings for the rest of the year.

F

Consistent with, what's in the work, plan.

F

≫≫ Right,, thank you very much., Subtitles by Premier Captioning, &, Realtime, Ltd. www.pcr.ie.