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From YouTube: CQC Board Meeting 20 November 2013
Description
Agenda for the meeting of the Care Quality Commission on 20 November 2013:
1. Apologies and declarations of interest 0:00:01
2. Minutes of the meeting held on 16 October 2013 0:00:33
3. Matters arising and action log 0:00:36
4. Chief Executive's report 0:00:55
5. Chief Inspector of Hospitals update 0:32:02
6. Chief Inspector of Adult Social Care update 1:06:06
7. Chief Inspector of General Practice update 1:20:30
8. Performance, finance and risk report 1:28:38
9. Audit and Corporate Governance Committee update 1:28:38
10. Board Forward Plan 1:28:38
12. Any other business 1:40:22
Read more about CQC's Board Meetings at
http://www.cqc.org.uk/public/about-us/our-people/board-members/board-meetings
A
Well,
welcome
everybody,
I'm
delighted
to
see
so
many
people
here
today.
I
must
just
pay
special
tribute
to
someone
on
the
front
row,
david
hogarth,
who
left
london
on
a
bus
at
11
o'clock
last
night
and
arrived
at
six
this
morning,
which
I
think
shows
a
huge
devotion
to
the
cqc
david
so
but
welcome
to
everybody
who's
here
today.
A
We've
got
no
apologies
for
absolutes.
Everyone
is
here.
Anna
is
joining
us
in
a
minute.
The
minutes
of
the
last
meeting.
Everyone
happy
with
the
minutes,
there's
only
one
matter
arising
which
has
been
dealt
with,
which
is
not
dealt
with
later,
and
that
is
that
we
are
not
going
to
do
the
thematic
review
on
to
microbial
and
infectious
infectious
diseases.
We're
not
going
to
do
that.
I
think
paul
we're
not
doing
that
excellent.
So,
chief
executive
report,
david.
B
Thank
you
chair
good
morning,
everybody.
You
will
have
a
supplementary
paper
to
board
colleagues
in
a
brown
envelope.
I'm
not
sure
what
members
of
the
public
will
have,
but
there'll
be
a
report
entitled
it's
number
11
and
it's
called
the
response
to
the
mid-staffs
inquiry
which
came
out
because
this
is
a
public
agenda.
The
report
was
published
yesterday
so
in
the
update
that
I'll
make
I'll
also
touch
on
that
report
in
the
post.
B
Francis
report,
if
I
may
so
just
turning
now
to
the
report,
the
it's
really
an
update
on
progress
against
a
number
of
key
issues.
Significantly
we've
had
a
report
back
from
a
gateway
review
that
has
been
taken
place
of
our
preparedness
in
relation
to
the
transformation
programme.
The
purpose
of
these
reviews
is
to
assess
our
readiness
to
actually
take
forward
the
changes
that
we
are
proposing
as
an
organisation
that
gateway
review
is
now
completed.
B
It
provides
external
scrutiny
by
people
that
are
not
connected
in
any
way
shape
or
form
with
cqc.
They
have
rated
the
program
amber,
which
is
effectively
a
judgment
that
says
good
progress
is
being
made,
but
there
is
risk
to
delivery.
Unless
action
is
taken
against
a
range
of
other
issues,
they
effectively
made
five
recommendations.
B
B
They
were
saying
less
process
and
more
focus
on
what
it
is
that
you're
going
to
deliver
by
when
I
would
add
that
to
a
number
of
people,
including
myself,
that
have
been
through
these
gateway
reviews
to
get
an
amber
review
on
the
first
is
actually
is
good,
more
serrated,
red
or
amber
red.
So
I
I
don't
want
us
to
be
complacent
about
this
in
any
way,
shape
or
form,
but
it
was
good
to
get
that
independent
review
and
that
independent
judgment
we've
asked
them
back
in
june
july
of
next
year.
B
B
B
Does
that
play
to
the
point
to
many
meetings
that
duplicate
too
much,
so
I
think
we've
obsessed
about
interdependence,
so
we
have
meetings
to
make
sure
that
this
piece
of
work
and
this
piece
of
work
are
connected
and
they're
saying
you
don't
need
a
meeting
to
check
that
out,
which
was
a
good
challenge,
so
we're
culling
meetings
really
to
make
sure
that
we're
clear
enough
about
what
needs
to
be
decided.
I
think
the
other
issue
is
be
clear:
what's
a
decision-making
meeting
and
be
clear,
what
is
a
meeting?
B
That's
about
planning
and
design
so
you're,
not
confusing
your
decision-making
governance
with
the
planning
and
design
work
that
you
need
and
again
a
good
challenge.
I
think,
and
if
you're
not
clear,
these
can
turn
into
talking
shops.
So
they're
really
saying
just
really
call
it
and
be
brutal
about
why
you're
meeting
what
the
purpose
is,
and
you
don't
necessarily
need
to
make
to
get
your
interdependencies
right.
You
can
do
that
in
other
routes,
so
make
sure
you've
got
a
person,
that's
in
common
that
is
charged
with
ensuring
independence.
B
A
B
It's
okay,
there's
documentation
on
this
being
worked
up
and
as
a
consequence
of
the
challenge,
this
was
already
being
prepared.
Interestingly,
in
terms
of
what
what
the
gateway
review
will
come
back
but
we'll
bring
that
to
the
december
board
and
I
think
it'll
be
in
a
good
state,
then
not
finalized
and
not
finished,
but
it'll
be
in
a
good
state.
I
think-
and
I
think
we've
been
able
to
develop
it
as
a
consequence
of
the
review
as
well
and
the
challenge
that
they've
provided,
as
I
say,
they
were
very.
B
B
B
B
Take
the
reformed
regulations
into
our
methodologies
consult
on
those,
so
we're
good
to
go
from
the
first
of
april
next
year
in
terms
of
changing
our
methodologies
around
hospital
inspections.
Currently
we're
enforcing
any
enforcement
action
with
our
new
inspection
will
be
taken
under
the
health
and
social
care
act,
as
distinct
from
the
regulations
that
exist
from
that.
What
we
want
in
new
regulations
which
give
force
to
our
new
methodologies,
so
we
enforce
our
new
methodologies.
So
this
is
a
this.
B
Is
the
oil
and
water
of
the
old
and
the
new
which
are
currently
mixing
to
give
us
our
legislative
position,
but
we
do
need
these
new
regulations
so
that
work
is
going
on
we'd
anticipated
they
would
be
available
by
now
and
they're.
Not
so
what
I'm
flagging
here
is
that
there's
work
going
on,
but
there
is
a
consequence
issue
that
we
may
need
to
address,
which
is
we
might
not
be
good
to
go
on
the
1st
of
april.
So
just
just
to
be
clear
about
that.
B
B
A
lot
of
media
attention
was
paid
to
the
issues
around
staffing
levels,
and
should
these
be
mandated,
should
they
not
be
mandated
coverage
also
to
the
implications
of
the
statute
duty
of
candor,
the
issue
around
criminal
offences
in
relation
to
behaviour
and
this
balance
between
creating
a
learning
culture
within
health
and
care
services
and
an
accountability
culture
and
how
that
balance
was
struck.
I
thought
what
the
secretary
of
state
was
doing
yesterday
is
trying
to
strike
that
balance
between
a
learning,
culture
and
accountability
around
criminal
offences.
B
B
Because-
and
this
was
his
argument-
there
are
many
different
ways
to
take
forward
recommendations
not
not
to
do
it
just
in
the
literal
way
that
he
set
them
out
and
he
felt
the
ambitions
that
he
had
for
the
changes
to
take
place
in
the
culture
of
health
and
care
services
were
being
taken
forward.
I
don't
want
to
speak
for
him
in
that
respect,
but
he
was
very
supportive
of
the
proposals
which
were
being
taken
forward.
E
My
feeling
is
that
what
really
matters
is
for,
at
a
ward
level,
every
ward
to
be
assessed
for
the
acuity
or
the
dependency
of
the
patient,
so
that
the
expected
or
the
planned
staffing
level
can
be
established,
and
that
needs
to
be
done
at
least
a
couple
of
times
a
year,
because
things
can
change
in
terms
of
what
the
average
dependency
is.
So
you
set
your
your
planned
level
and
then
should
report
against
that
and
and
the
the
statement
yesterday
was
that
the
people
should,
on
a
monthly
basis,
report
actual
against
planned.
E
I
believe
that
this
is
a
very
sensible
way
forward,
because
the
the
needs
on
different
wards
are
very
different.
If
you're
on
a
hyper,
acute
stroke
unit,
you
may
need
a
ratio
of
one
to
four
on
a
pediatric
wall
depending
on
the
dependency.
It
might
be
one
to
five
something
like
that
on
other
wards.
It
may
be
one
to
eight.
I
think
there's
a
real
risk
that
if
the
one
says
just
one
to
eight
that
could
become
the
norm
and
there
could
be
a
leveling
down,
and
I
think
that
would
be
a
great
disadvantage.
E
So
in
our
data
packs
for
our
acute
hospital
inspections,
we
have
the
friends
and
family
test
results
by
ward
and
I
can
look
down
those
very
quickly
and
I
can
say
well
whatever
else.
We
must
go
to
those
wards
because
they've
got
the
least
good
friends
and
family
test,
and
we
may,
we
will
always
go
and
see
a
range
of
wards
within
any
hospital.
So
I
think
this
combination
of
getting
them
to
set
their
staffing
levels
measure
against
it
and
put
that
alongside
good
safety
data
will
actually
be
very
powerful.
F
This
is
partly
about
staffing,
but
probably
about
the
report
in
general.
I'm
also
relieved
to
hear
david
that
you
felt
the
balance
was
properly
set
between
culture
and
the
use
of
the
law,
because
I
think
what
came
across
was
the
use
of
the
law
rather
than
culture,
and
that
would,
if
that
were
allowed
to
get
around.
I
think
that
would
be
that
would
go
down
badly
with
staff
who
would
otherwise
respond
well
to
the
ethic
of
learning
the
phrase
that
berwick
used
and
it's
the
ethic
of
learning
that
needs
to.
F
We
need
to
focus
on.
Yes,
that's
have
legal
measures
that
occasionally
take
people
to
court
if
they've
done
something
willful
and
reckless
as
berwick
said,
but
otherwise
this
is
about
changing
the
culture
of
the
service
and
our
messaging,
I
hope,
will
be
focusing
on
changing
the
culture
of
the
service
and
not
on
the
the
legal
measures
which
may
be
used
in
extreme
cases,
but
which
berwick
himself
said
would
have
very
little
effect
on
safety.
F
On
the
issue
of
staffing,
I
wouldn't
underestimate
the
potential
for
gaming
on
this.
The
when
I
was
national
director
for
mental
health,
we
I
thought
it
would
be
helpful
to
publish
per
capita
spending
on
mental
health
nationally
by
pct,
because
I
because
there
was
such
a
lot
of
controversy
about
the
variation
and
so
we
did
publish
it
and
and
then
I
began
to
hear
that
the
pcts
that
had
come
out
rather
well
we're
starting
to
say
well
we're
spending
too
much
on
mental
health.
F
It's
about
time
that
we
were
spending
less,
because
we
were
sort
of
outliers
at
the
top
end.
So
to
speak
and-
and
the
detail
here
will
be
crucial
mike,
as
I'm
sure
you're
well
aware.
The
you
know,
there's
a
even
the
keo
review
into
some
of
the
trust.
A
few
months
ago
commented
that
the
information
that
was
being
put
out
given
to
them
by
trust
was
not
accurate
and
which
they
discovered.
When
they
went
to
inspections.
F
They
said
that
people
were
recorded
as
having
a
certain
level
of
staffing
or
trust
having
a
certain
level
of
staffing,
but
that
didn't
reflect
the
the
seniority
and
experience
of
the
staff
which
was
not
adequate
and
they
didn't
mention
the
fact
that
some
of
the
staff
who
were
being
counted
were
agency
staff.
Now
these
things
will
have
to
be
overcome,
otherwise
the
system
will
be
will
be
discredited.
B
So
thanks:
let's
do
those
in
reverse
order.
I
think
it's
29,
but
let
me
check
that
and
I'll
give
you
the
figure,
but
I
don't
think
any
of
those
have
got
gagging
clauses.
So
what
we're
asked
to
do
is
actually
write
to
make
sure
that
there
is
nothing
in
those
and
confirm
this
in
writing
to
each
individual.
B
That
has
had
a
compromise
agreement
that
there
is
no
way
that
we
expect
them
or
debare
them
for
speaking
out
if
they've
got
a
genuine
concern
so
that
that's
the
nature
of
the
letter,
that's
effectively
what
the
health
select
committee,
we're
asking
us
to
give
further
reassurance
on
that.
Those
confidentiality
agreements
were
not
going
to
be
used
to
stop
people
speaking
out
if
they
are
genuine
concerns
and
we'll
do
that,
and
we
confirm
we'll
do
that
by
the
end
of
at
the
end
of
this
month.
They
are
historic.
B
They
all
they
go
back
to
the
beginning
of
cqc,
which
is
why
I
just
can't
do
the
figure
off
the
top
of
head
lewis.
I
think
I
think
it's
about
29,
so
we've
we've
confirmed
we'll
do
that
and
arrangements
are
in
place
in
terms
of
greater
independence
effectively.
What
this
means
is
an
example
would
be
under
the
current
legislation
in
order
to
do
an
inverted
commas
of
special
study
to
use
our
section
48
powers
to
do
a
special
study.
B
The
way
the
current
legislation
is
drafted
is
we
would
have
to
ask
we'd
have
to
consult
with
the
secretary
of
state
to
do
that
special
study
and
what
the
greater
independence
does
is.
It
removes
any
requirement
for
us
to
ask
the
secretary
of
state
for
permission
to
discharge
our
responsibilities
and
it
affirms
our
operational
independence
from
the
secretary
of
state,
so
any
judgments
that
are
made
about
the
quality
of
service
and
indeed
any
ratings
that
we
issue
are
done
by
cqc.
B
So
that's
what
he'll
give
force
to
it
or
remove
that.
I
think,
on
the
wider
point
about
this
balance,
I
think
it
feels
a
long.
It
feels
like
we've
been
preparing
for
what
we're
going
to
say
about
robert
francis's
report
for
a
long
time,
and
I
thought
the
watershed
yesterday
was
actually.
This
is
now
about
delivery.
This
isn't
about
the
arguments
about
who's,
going
to
do
what
and
how
this
really
is
about
getting
on
and
doing
it.
B
I
think
we've
been
doing
that
to
a
certain
extent
by
the
fact
that
mike's
always
seen
13
of
these
18
inspections
being
done
and
we've,
so
it
felt
from
my
point
of
view
positive
yesterday
to
be
able
to
say
not.
We
are
we
intend
to
do
this,
but
we
are
doing
this
and
I
think
the
fact
that
we
got
the
surveillance
out
in
october.
We've
got
the
inspections
underway
and
the
four
reports
published
tomorrow
was
a
sense
of
that.
B
I
thought
bowick's
report
without
using
this
phrase
was
another
exposition
of
what
the
just
culture
is
about,
how
you
get
that
balance
between
supporting
and
having
an
accountability
at
the
end,
and
it's
something
that
we've
talked
about
in
cqc
and
certainly,
I
think,
influences
the
way
we're
trying
to
build
and
design
both
what
we
do
internally
in
cqc
and
what
we
do
in
terms
of
our
methodologies
so
is
to
play,
for.
I
think.
A
I'm
just
going
to
ask
anna,
but
just
before
I
mean
just
to
the
three
chief
inspectors,
I
mean
that
point
that
lewis
made
and
that
david
just
referred
to
getting
this
balance
right
between
accountability
and
learning.
I
think
we're
all
one
on
this.
Aren't
we
that
it's
getting
a
learning
culture
into
these
organizations
is
the
most
important
thing.
B
G
I
I
would
agree
completely
just
as
a
note
on
staffing
when
we
start
to
look
at
general
practice
and
primary
care.
I
think
there
are
staffing
issues
there
as
well,
particularly
a
warning
for
any
gps,
watching
this
board
meeting
that
I
can't
see
how
general
practitioners
can
deliver
their
services
without
nurses
and
we're
finding
examples
of
gp
surgeries
without
practice,
nurses,
and
so,
whilst
the
attention's
been
on
hospitals.
H
Yes
and
two
things,
one
on
the
balance
between
the
the
learning
culture
I
mean,
I
think,
that's
where
the
question
about
is
the
service
well
led,
really
really
comes
into
its
own
in
terms
of
looking
at.
Are
we
our
organizations
aware
of
what
they
need
to
be
supporting
their
staff
to
deliver
and
making
sure
that
those
arrangements
are
in
place?
And
and
it's
you
know,
it
will
be
a
critical
aspect
of
the
questions
that
we
will
ask
in
adult
social
care.
C
Very
much
I
I
I
just
wanted
to
pick
up
on
what
you
were
saying,
david,
about
moving
from
kind
of
waiting
for
the
all
the
responses
to
francis
and
all
the
associated
reports
and
in
in
into
delivery.
Because
I
mean
I
think
it.
It
must
be
a
a
good
thing
for
us
in
terms
of
the
sort
of
uncertainty
of
the
environment
in
which
we
operate,
that
you
feel
that
we've
got
to
the
point
where
actually
everyone
has
that
knowledge?
C
That's
that's
that's
the
set
of
answers,
at
least
to
this
report,
and
I
know
there's
no
accounting
for
events
and
circumstances
which
could
throw
us
off
course
again,
but
but
but
but
bearing
in
mind
the
set
of
work
which
is
now
foreseen
in
the
in
in
this
final
response.
How
how
long
do
you?
What's?
Your
kind
of
I
know
it's
a
slightly
finger
in
the
air
at
the
moment,
but
how?
How
long
will
we
be
working
on
this
set
of
propositions?
B
B
Normally
in
a
gateway
review,
they'd,
say
you're
running
too
hot,
put
something
in
there
to
cool
it
down,
but
they
acknowledge
that
we've
got
a
whole
set
of
things
that
we're
committed
to
do
by
due
dates
and
running
hot
is
what
we
need
to
do.
So
a
lot
of
their
advice
was
about
slimming
it
down
being
more
efficient
about
what
you're
doing
so
you
can
deliver
what
you've
set
out
to
do
without
putting
too
much
effort
into
the
kind
of
process
of
it.
B
I
think
our
public
statements
about
what
we
will
do
by
when
I
think
this
is
the
significance
of
the
signposting
documents
which
are
beginning
to
say
this
is
what
we're
going
to
do
by
when
this
is
the
detail.
We're
working
towards
these
are
hugely
important
documents
for
people
that
we
work
with
stakeholders,
people
in
the
system
to
get
a
sense
of
what
we
are
doing.
B
It
will
be.
The
first
thing
that
we'll
have
said
of
this
is
how
we
think
we're
going
to
do
our
work.
This
is
how
we're
going
to
do
our
work
on
community
healthcare,
so
this
is
a
signal
to
the
system.
These
are
hugely
significant
documents.
The
first
thing
that
steve's
actually
said
in
writing
about
what
we're
going
to
do
in
the
future.
B
So
I'm
confident
about
that
work,
I'm
confident
that
we're
bringing
in
the
capability
and
capacity
through
some
con
additional
consultancy.
I
know
we'll
talk
about
those
issues
later
this
morning,
but
by
bringing
that
additional
capacity
in
by
being
clear
about
what
we
intend
to
do
by
when
I'm
confident
that
we'll
do
the
work
that
we've
set
out.
I
think
the
important
thing
and
we've
got
this
question
at
the
health
select
committee
and
we're
getting
it
a
lot
about.
Are
you
giving
enough
priority
to
this?
B
B
We
shouldn't
say
these
are
the
priorities
and
therefore
stick
to
them,
but
we
constantly
need
to
be
judging,
I
think,
mike's
point
about
staffing
levels
in
organizations
is,
you've
got
to
be
constantly
reviewing
them
and
judging
them
and
whether
you've
got
the
right
people
in
the
right
place
and
the
right
things
and
in
the
same
way,
I
think
we've
got
to
constantly
review
and
judge
whether
we're
doing
the
right
things
in
the
right
way
and
that's
what
all
do
so.
Yes,
I'm
confident,
but
we're
running
hot
and
there's
risk.
D
D
I
wonder
whether
we
as
a
board
in
our
forthcoming
strategy
session.
We
should
really
give
well
ledness
a
really
big
to
the
cut
a
lot
more
on
it
with
respect
to
the
government's
response,
whether
we
think
there's
more,
that
we
could
be
doing,
and
also
similarly
with
those
in
monitoring
the
tda
on
acute
hospital
side
to
make
sure
that
we
have
a
can.
There
is
some
kind
of
kind
of
consensus
about
what
we
think.
Worldwideness
really
is
because
it
really
does
underpin
everything
and
we
could
send
a
very
powerful
signal.
D
Couldn't
we-
and
I
know
there
will
have
been
quite
a
bit
of
discussion
on
this
already,
but
I
do
think
in
the
light
of
this,
because
it
doesn't
come
out
in
the
headlines.
You've
said
whether
or
not
we
should
revisit
it
in
our
strategy
with
monitor
and
then
that
might
set
the
scene
for
the
general
practice
and
the
social
care
side.
If
we've,
if
we've
bottomed
it
out
a
little
bit
more,
I
think
it's
worth
some
attention.
A
No,
it's
a
very
good
point.
Jennifer
I
mean
we
are
doing
the
work
with
king's
fund,
as
you
know,
I
think,
and
with
michael
west,
at
lancaster
university
to
come
up
with
a
more
definition
around
the
worldness,
we're
doing
that
with
monitor
as
well,
so
that
the
two
are
completely
joined
up
on
that.
But
I
think
at
december
we've
got
we'll
come
back
to
you
and
show
you
what's
been
done
in
december.
If
we
can,
it
is
absolutely
underpins
everything.
That's
going
on.
B
Yeah,
so
if
I
can
just
go
to
paragraph
eight
in
the
report,
the
human
factors
concord
that
really
links
to
this.
This
is
one
of
the
supporting
papers
published
by
the
national
quality
board,
which
really
takes
some
of
the
thinking
that
beric
and
others
have
used
and
publishes
a
separate,
well
think
piece,
really
a
concord
app,
which
is
saying
people
will
work
to
this
after
our
this
report
was
produced.
B
The
nqb
also
published
a
report
on
staffing
levels
as
well,
which
informed
the
debate
yesterday,
paragraph
seven,
I'm
drawing
attention
to
the
terms
of
reference
which
dr
bill
kirkup
has
announced
in
relation
to
the
method
statements
he's
going
to
use
in
relation
to
the
inquiry
that
he
will
lead
in
relation
to
maternity
services.
That
more
can
be
a
number
of
current
and
former
staff
may
be
called
to
give
evidence
of
that
inquiry.
B
They've
been
written
to
advise
them
in
terms
of
reference
to
their
inquiry
and
prepared
for
the
fact
that
they
may
be
asked
to
make
a
contribution
to
that.
It's
not
an
enquiry
into
cqc.
It's
an
inquiry
into
maternity
services.
That
more
can
be
it
clearly,
as
cqc
regulated.
Those
services
it
is
likely
that
we'll
be
asked
to
make
a
contribution
to
it,
and
the
last
thing
david
on
the
report
is
just
to
update
that
we're
now
underway
for
recruitment
to
deputy
chief
inspectors.
B
E
E
We
are
well
underway
with
wave
one
of
the
acute
hospital
inspection
program,
as
people
will
remember,
we
aim
to
inspect
18
trusts
during
this
period
and
those
were
selected
as
being
a
combination
of
ones
that
we
thought
were
high
risk.
We
thought
were
low
risk
and
we
thought
were
intermediate
risk
and
we
have
got
at
least
to
the
the
site
visit
stage.
The
plan
site
visit
stage
for
13
of
those
18
that
and
and
they're
listed
there.
E
I
was
at
the
one
at
airedale
and
that
quality
summit
has
a
sitting
around
the
table,
apart
from
ourselves
from
cqc
and
representatives
of
the
trust
representatives
of
monitor
in
that
case,
because
it
was
a
foundation,
trust
the
local
ccgs
healthwatch,
the
local
health
watch
and
nhs
england,
and
we
presented
our
report
and
the
plan
is
that
that
report
will
be
published
tomorrow
and
the
the
trust
then
responded
to
the
report.
And
then
the
third
part
of
the
meeting
was
action
planning.
E
That
section
is
led
by
monitor,
as
opposed
to
by
by
us,
because
clearly
we
are
not
responsible
for
doing
the
quality
improvement,
but
we
were
party
to
that
so
that
we
can
at
least
hear
what
is
being
planned
that,
but
that
will
help
us
also
to
know
when
we
might
want
to
go
back
in.
So
I
think
for
at
least
that
first
group
of
four
we've
now
got
through
to
that.
E
That
sort
of
third
step
in
the
in
the
process
we
are,
I
think,
the
informal
feedback
has
been
positive
so
far,
we're
doing
a
formal
evaluation,
but
but
that
will
only
come
through
when
we've
completed
wave
one.
But
I
think
what
is
also
important
to
say
is
that,
with
almost
every
inspection
we
are
modifying
the
process
a
little
bit.
E
But
it
is
still
early
days.
So
I
mean
certainly
not
saying
that
everything
is
going
as
we
would
want
it
to
long
term,
but
it
is
going
and
the
trust
that
we've
been
to
have
been
very
courteous
and
have
also
said
that
they've
come
back
with
positive
comments
on
how
we've
gone
about
it.
And
so
I
think
all
is
is
okay,
but
could
be
improved.
E
The
14
of
those
we've
got
to
do
those
all
before
the
summer,
so
we're
getting
some
of
them
done
before
easter.
So
that's
the
acute
side
on
the
mental
health
and
community
services
side
we're
making
rapid
progress,
but,
as
I've
said
before,
to
the
board,
we
are
committed
to
having
parity
of
inspection
as
well
as
parity
of
esteem,
by
which
I
mean
that
we
are
committed
to
getting
through
to
the
end
of
the
community
and
mental
health
trust
inspections.
E
E
We
believe,
and
we've
had
lots
of
work
with
external
reference
groups
on
this,
that
the
same
broad
principles
will
apply,
in
other
words,
getting
as
much
data
in
as
we
can
before.
We
go
on
site,
taking
a
large
team
with
us
and
visiting
lots
of
different
areas
within
a
trust
and
then
the
the
report
back
and
quality
summit.
But
obviously
what
we
consider
to
be
core
services
within
community
health
or
mental
health
will
be
quite
different
from
the
ones
that
we
would
say
for
acute
services.
E
One
of
the
the
challenges
will
still
be.
Can
we
visit
or
what
services
should
we
visit,
because
they
are
scattered
over
large
geographical
areas
and
a
lot
of
the
services
are
given
in
people's
homes
and
we
can't
possibly
inspect
all
of
those,
and
we
are
taking
again
an
approach
which
is
based
on
where
we
think
the
highest
risks
lie.
So,
for
example,
all
inpatient
services.
E
We
feel
that
we
should
assess,
and
I
think
that
another
thing
to
say
is
that
the
the
level
of
data
we're
likely
to
have
before
we
go
on
site
either
for
mental
health
or
community
services
will
not
be
as
detailed
as
we
have
for
for
acute.
I'm
not
saying
it's
perfect
for
acute.
It
isn't,
but
there
is
still
some
way
to
go
on
that.
E
E
E
We
ran
effectively
three
separate
teams
in
parallel.
We
might
well
run
two
tech
teams,
but
with
the
relevant
expertise
in
parallel,
but
almost
certainly
staying
in
the
same
hotel.
So
we
are
feeding
back
and
exchanging
views
of
which
will
contribute,
I
think
very
much
to
how
well-led
the
trust
is
as
a
whole
and
that
that
bill,
which
will
overlap,
distinctly
the
final
bit.
You
you
asked
the
last
board
meeting
for
an
update
on
involvement
of
patients,
users
and
carers
in
in
the
hospital
program
as
a
whole.
E
We
obviously
already
do
have
them
involved
in
the
acute
hospital
inspection
program.
We
tend
to
have
five
or
six
experts
by
experience
on
each
of
our
inspection
teams.
What
that
means
is
that
they
can
then
split
up
so
that
there
is
one
on
each
sub-team,
so
there
will
be
a
sub-team
looking
at
a
e
or
a
sub-team,
looking
at
maternity,
one
looking
at
medical
awards,
etc,
and
so
that
the
idea
is
that
on
every
one
of
our
sub-teams,
we
do
have
an
expert
by
my
experience
and
we
are
finding
their
their
input
hugely
valuable.
E
We
are
also
in
advance
of
going
on
site,
doing
more
and
more
reaching
out
to
specific
local
communities,
an
example
being
the
week
before
we
inspected
salford.
There
had
been
engagement
with
the
local
jewish
community
and
that
provided
very
useful
feedback
in
advance
of
our
visit.
We
have
a
a
listening
event
on
each
of
our
inspections
and
increasingly
we
are
also
getting
a
patient
perspective
by
analyzing
complaints.
E
That's
something
that
we
were
only
starting
to
do,
but
I
think
really
from
this
next
group
we
will
be
doing
more
and
more
of
so
and
we
are
open
to
suggestions
about
how
what
more
to
do
on
any
of
those.
So
I
think
my
conclusion
is.
We
are
now
well
underway.
There's
lots
of
modifications
that
we
will
make.
We've
got
a
small
break
between
wave
one
and
wave
two,
in
which
case
we
will
reflect
and
try
and
improve,
and
then
we'll
get
cracking
with
mental
health
and
community
services.
D
Thanks
thanks
mike,
I
had
the
opportunity
to
join
one
of
the
inspections
for
a
couple
of
days,
and
I
was
the
thing
that
struck
me.
The
most
was
the
sort
of
enthusiasm
by
various
sort
of
clinicians
workers,
patients
experts
by
experience
to
actually
enthusiasm
to
get
involved
and
to
help
us
get
it
right
and
also
valuing
the
opportunity,
and
I
think
that's
a
real
kind
of
positive.
So
I
have
two
kind
of
questions.
One
I
think
is
about
the
evaluation
and
two
aspects,
one,
the
intelligent
monitoring
tool.
D
I
know
that
when
we
did
our
consultation
on
our
strategy,
there
was
some
people
that
felt
that
the
standards,
the
fundamental
standards
or
the
expected
standards
there
wasn't
sufficient
clarity.
And
so
I
wondered
you
know
from
the
first
wave
of
inspections,
whether
it's
becoming
clearer
to
us,
how
we
are
going
to
define
them,
explain
them
and
assess
against
them,
and
whether
that's
part
of
the
evaluation
and
final
final
point
is
on
the
mental
health
inspections
and
we're
prioritizing
those
that
want
to
be
foundation
trusts.
D
E
Right,
I
agree
with
you
about
the
the
enthusiasm
of
the
teams.
It's
huge
in
terms
of
evaluation.
We
are.
The
evaluation,
will
look
at
everything
that
we
are
doing
and
we
have
an
external
team
who
are
accompanying
us
on
these
inspections
but
they're,
looking
at
all
all
aspects
of
it
and
I
think
you
may-
I
have
met
some
of
them.
The
intelligent
monitoring
tool
and
paul
may
wish
to
add
to
this.
I
think
one
of
the
things
we're
testing
in
wave.
E
One
is:
what
is
the
relationship
between
what
we
saw
on
intelligent
monitoring
and
what
we
see
when
we
we
get
on
the
ground
and,
frankly,
until
we've
done
all
18.
I
don't
think
we're
in
a
position
to
judge
that
one
properly.
So,
in
other
words,
do
those
that
appear
to
have
low
risk
look
good
or
whatever,
when
we
when
we're
there
and
do
those
that
appear
to
have
high
risk
actually
have
lots
of
challenges.
E
Paul
is
probably
in
a
better
position
to
speak
about
that,
but
what
we
have
done
is
to
try
and
include
those
indicators
that
we
think
are
robust
at
a
national
level
and
that
cover
all
five
questions
so
that
that's
the
balance
that
we're
going
for,
and
certainly
I
find
it
it's
a
useful
starting
point,
but
I
don't
think
any
of
us
are
expecting
it
to
be
the
be
all
on
end
all
if
it
was.
Why
would
we
need
inspection?
E
But
you
know
I
would
have
a
very,
very
easy
job
because
I
just
say
paul
give
me
the
intelligent
monitoring
answer
and,
and
that
that's
my
verdict.
So
it
really
is
we
a
combination
of
what
we
see
in
the
data
and
what
we
see
on
the
ground,
the
the
fundamental
standards.
Well,
as
you
will
know,
the
fundamental
standards
are
are
in
the
process
of
changing
in
this
phase.
Of
course,
what
we're
saying
is
where
we
see
serious
breaches
of
of
standards.
E
We
are
very
much
being
encouraged
by
our
colleagues
at
the
trust
development
authority
and
monitor
to
get
some
of
these
ones
through,
and
I
think
what
we
feel
is
that
at
this
stage
we
can
develop
a
good
enough
approach
to
assessment
to
be
able
to
make
that
judgment.
Are
they
ready
for
foundation
trust
status?
But
we
are
it'll,
take
us
longer
to
get
to
the
point
where
we
can
really
rate
mental
health
or
community
service
trust,
so
we're
in
a
learning
phase.
Basically,.
F
Lewis,
thank
you.
Well,
my
first
question
is:
was
going
to
be
the
same
one
that
kay
asked
about
the
link
between
the
surveillance
and
the
inspections.
Presumably
in
the
end,
that
is
one
of
the
key
questions
which
the
inspections
are
asking
not
just
about
themselves,
but
about
how
they
got
there
in
the
first
place
and,
of
course,
about
among
all
the
questions
you
could
ask
about
that,
there's
one
that
is
more
important
than
any
other.
That
is
about
the
false
negatives.
F
And
so
it's
the
the
where
the
surveillance
says.
Things
are
okay,
but
the
inspection
shows
that
they're
not
are
they
missing?
Is
our
system
missing
anything
so
that
when,
when
I
take
your
point
that
we
have,
we
don't
know
yet,
because
we
have
you
know
that
long
enough,
but
in
the
end
that
will
be
the
critical
question.
I
Yeah
without
a
shadow
of
a
doubt,
we
will
miss
things
with
intelligent
monitoring.
There
will
be
false
negatives.
We
know
that
from
the
13
already
we
go
on
sites
on
ones
I've
been
on
with
with
mike.
We
will
find
individual
awards
that
simply
weren't
picked
up
as
as
having
poor
care
through
our
intelligent
wanting
most
of
our
intelligent
monitoring.
Metrics
are
hospital
level,
not
all
of
them.
I
Some
of
them,
like
the
friends
of
family
tests,
do
go
down
toward
level,
but
fundamentally
they
are
only
the
top
tier
of
all
the
intelligence
that
we
have
the
ones
that
are
genuinely
nationally
comparable.
So
we
have
a
whole
set
of
tests
that
exclude
a
bunch
of
metrics.
It
doesn't
mean
we
don't
use
them,
but
there
are
undoubtedly
false
negatives.
I
It
will
get
better,
for
example,
in
the
as
david
mentioned,
his
update
there
when
we
get
the
ward
level
staffing
data.
That's
part
of
the
response
government's
response
to
francis
that's
something
we'll
be
able
to
feed
in,
but
there
is
a
fundamental
difference
between
all
the
things
that
we
know
before
we
go
on
site,
which
is
all
about
helping
pre-populate
our
views
on
where
to
go,
and
in
some
instances
inform
the
the
likely
rating
and
the
judgment
that
mike
and
his
teams
make
that's
a
definitive
judgment
on
quality.
I
F
There's
got
to
be
a
lingering
concern
that
the
the
the
the
visits,
even
though
they
are
much
strengthened,
are,
are
still
snapshots
of,
what's
happening
in
a
in
a
service,
a
bigger
snapshot
or
a
sort
of
moving
snapshot
of
the
research,
but
snapshot
just
the
same.
And
if
I
just
give
you
a
an
example
when
I
was
a
medical
student,
I
worked
in
as
a
nursing
assistant
in
a
long
stay
asylum
and
just
to
reassure
you.
F
But
unless
you
turned
up
at
cigarette
time,
you
wouldn't
have
got
the
snapshot,
you
needed
to
know
what
was
really
happening
and
what
people's
experience
really
was
like.
So
I
want
you,
I
just
I'm
not
telling
you
anything.
You
don't
know
mike,
but
it's
just
as
important
that
the
cigarette
time
in
the
long
stay
asylums
is
you
have
that
in
mind
when
you
conduct
even
this
more
robust
snapshot.
F
We
need
a
science
of
complaints
at
the
moment
it
is
still
very
much
about
understanding,
what's
presented
in
a
qualitative
form
and
that's
very
variable,
the
people
who
complain
and
not
necessarily
typical
of
people
who
use
services.
That
doesn't
mean
it's
not
important,
but
it
it.
It
means
that
some
voices
have
gone
unheard
and
some
may
be
more
powerful
than
and
prominent
than
they
than
is
fair
on
the
service.
E
Just
I
agree
with
what
paul
was
saying:
you
know
we
will
miss.
We
know
there
will
be
false
negatives.
The
other
point
about
that,
to
my
mind,
is
that
it's
only
by
inspecting
that
we
get
to
understand
the
whys
of
what's
going
on
with
it
with
it
within
a
hospital
or
a
service
and
from
having
done
one
complete
inspection.
E
All
days
of
one
inspection,
I
was
uncertain
at
the
beginning
of
the
week.
I'd
read
the
data
pack
carefully.
I
knew
what
what
was
wrong
in
terms
of
a
e
or
whatever.
Would
I,
by
four
days
later,
really
understand
what
was
going
on
in
that
hospital?
I'm
sure
there
are
bits
of
the
hospital
I
don't
understand,
but
I
did
have
a
broad
understanding
that
we
could
feedback
to
the
trust
and
indeed
to
the
trust
of
developmental
authority,
which
I
think
was
helpful.
So
I
think
we
get
to
an
understanding
as
well.
E
Have
we
changed
the
system?
I
can
give
you
anecdotes
of.
What's
already
been
done,
there
was
a
porter
who
had
been
annoyed
that
the
squeaking
door
had
not
been
dealt
with
for
two
years,
who
came
and
mentioned
it
to
us.
We
escalated
it
and
that
door
was
not
squeaking
by
the
end
of
the
day
and
we
went
back
and
checked
so,
but
but-
and
there
are
other
things
as
well-
that
we
could
point
to.
I
agree
with
you
about
snapshots.
E
Remember
that
we
are
on
site
for
long
hours
and
we
don't
just
go
to
a
ward
in
the
morning.
We
may
then
go
back
to
the
same
ward.
That's
that
same
evening,
out
of
hours
and
cert,
not
in
our
inspections,
but
in
the
keo
inspections.
I
do
know
of
cases
where
ward
said:
oh,
we
weren't
expecting
you
back
and
and
and
so
we
we
will
do
that
and
we
will
go
there
at
whatever
times.
E
But
we
are
already
using
them
to
point
us
to
which
directions
within
a
hospital
outside
our
core
services.
We
ought
to
be
looking
at
and
we're
already
using
the
complaints
to
see
whether
there
is
a
learning
culture.
Very
simple
question
to
whoever
is
in
charge
of
complaints
or
to
the
chair
of
the
trust.
You
know
what
have
you
actually
changed
as
a
result
of
of
of
complaints,
and
there
are
some
trusts
that
have
given
us
very
detailed
answers
to
that
of
fairly
major
changes
that
have
been
made.
A
C
So,
okay,
so
I'll
be
as
quick
as
possible.
So
three
questions
mike
the
the
but
very
quick
ones.
One
is
about
just
about
bart,
so
I'm
really
interested
how
this
model
worked.
Your
head
of
top
of
the
head
thoughts
about
how
this
works
in
such
a
huge
hospital
complex
because
we
were
concerned
about
that.
So
so
how
did
it
work?
I
just
want
to
go
back
to
the
point
that
k
made
because
I
I
do
agree-
and
I
had
this
as
well-
about
the
selection
of
mental
health
trust
and
I
I
remain
concerned.
C
I
understand
the
issues,
but
I
remain
concerned
that
we've
got
something
which
is
being
driven
by
foundation,
trust
status
and
not
by,
but
by
any
extent
of
risk,
and
I
think
there
must
be
some
proxies.
It
will
be
far
less
far
less
sort
of
robust
even
than
our
intelligent
monitoring
system
as
it
stands.
But
I
I
just
think
there
must
be
some
ways
by
by
talking
to
some
of
those
people
who
who
perhaps
particularly
represent
users
of
these
services
so
cut
through
and
just
identify
some
places
that
they
think
are
high
risk.
C
And
I
would
like
to
see
them
in
this
list
and
the
the
final
thing
was
about
the
stuff
that
you
we
asked
you
to
give
us
and
you've.
Given
us,
and
I
I
absolutely
recognize
about
users
and
carers
being
involved
in
this
system,
and
I
absolutely
recognize
that
that
that
you
have
made
huge
strides
and
huge
efforts
to
engage
with
people
and
to
listen
to
people,
because
that
was
a
key
message
of
francis
and
something
you've
tried
to
do
here.
C
A
E
The
third
one
to
you,
if
I
may,
in
terms
of
bart's,
it's
a
hugely
complex
trust,
and
I
think
it's
complex
for
the
trust
to
run
it's
complex
for
us
to
assess.
I
think
the
the
parallel
teams
really
work
quite
well,
whether
in
the
future
I
would
have
three
teams-
or
maybe
I'd,
make
it
two
and
just
for
a
bit
more
simplicity.
E
I
think
the
only
point
I
would
make
here
is:
we
have
actually
pulled
forward
the
program
to
start
in
january
in
order
that
we
can
get
learning
and
we
we've
decided
to
learn
on
ones
that
I
don't
know
what
risk
we
will
find
when
we
get
in.
I
honestly,
don't
know.
All
I
know
is
they
are
aspiring
to
be
foundation
trusts,
but
I
can
give
you
an
assurance
that
if
we
can
work
out
some
way
of
assessing
risk
from
april
onwards,
we
will
do
high-risk
ones,
then,
by
all
means.
I
Yeah
I
mean
it's
worth,
adding
to
what
mike
said
that,
wherever
the
those
comprehensive
inspections
are
just
that
they
will
lead
to
a
rating,
but
where
we
have
any
concerns
about
safety,
and
we
do
have
concerns
about
safety
in
some
mental
health
trusts,
we
will
go
in
anyway.
So,
for
example,
we
took
a
team
of
10
people
into
a
mental
healthcare,
one
particular
unit
in
september,
if
I
remember
rightly
so-
we're
not
in
any
way
pausing
the
existing
program,
it's
what
we
do
on
top
of
it.
K
I
could
be
interested
to
know
about
the
quality
of
those
responses,
because
if,
if
I
think
they're
gonna
need
some
assistance
not
from
us,
but
if,
on
the
other
hand,
they
fall
down,
we
fall
down.
I
think
that's
my
my
anxiety
here
and
I
think
we've
prepared
incredibly
well
for
what
is
something
very
new.
I'm
just
not
sure
that
prepared.
They
are
that
prepared
for
something
that
is
very
new,
and
that
might
mean
there
will
be
a
stutter
in
these
first
few
and
the
sooner
we
know
about
that.
A
C
Thank
you
mike.
I
just
wondered
if
you
could
tell
us
a
bit
about
colchester
and
what
we've
learned
from
it,
because
the
impression
from
the
outside,
I
think,
is
that
it
was
quite
a
lucky
chance
that
a
whistleblower
happened
to
point
someone
in
the
direction
of
the
problems
with
the
cancer
waiting
times
and
that
keo
and
we
might
not
have
picked
up
on
that.
Had
it
not
been
for
that.
So
I'm
just
interested
in
your
reflections
on
that
and
also
on
what
we
mean
by
special
measures
and
how
you
see
that
going
forward.
E
I
I
wouldn't
describe
it
as
lucky
chance,
although
there's
an
element
of
that.
I
think
it
is
the
very
fact
that
the
keo
team
were
on
site
that
emboldened
the
whistleblower
to
to
come
forward,
and
I
I
think
that
may
well
be
part
of
what
we
find
with
our
program,
that
that
will
encourage
people
who've
not
had
the
carriage
up
to
that
point
to
say
anything
to
to
come
and
speak
to
the
team.
So
what
happened
was
that
the
whistleblower
came
to
the
keo
team.
The
keo
team
escalated
it
to
cqc.
E
Cqc
undertook
a
very
rigorous
inspection
of
this
specific
point
and
that
involved
looking
at
computers
and
whether
things
might
have
been
changed
on
computers.
It
involved
looking
through
case
records
and
speaking
to
patients.
So
it
did
a
very
a
good
job
there,
which
did
reveal
a
problem,
and
at
that
point
and
taking
that
into
account
alongside
what
the
keo
inspection
had
shown,
I
think
that
that
gave
us
real
cause
for
con
concern,
which
is
at
the
point
that
I
then
discussed
it
with
monitor
and
said.
E
C
E
I
think
what
it
means
is
that
they
then
need
to
do
a
much
more
detailed
look
at
the
governance
of
that
organization,
something
that
that
we
were
not
doing
as
part
of
our
cancer
weights
inquiry
and
which
was
probably
done
at
a
level
by
keo
but
needs
to
be
much
more
detailed.
I
do
not
know
who
knew
what,
within
the
the
the
the
culture
investigation
that
that
I'm
not
privy
to,
but
I
think
that
allows
monitor
to
say
yes,
we
we
will
now
look
in
detail
at
governance
within
that
organization.
B
On
that,
because
there's
also
a
potentially
a
criminal
investigation
taking
place
that
runs
alongside
that.
So
the
saw
what
question
I
think
is
a
really
important
one.
I
think
it
then
comes
into,
and
this
is
the
willfulness
that
I
think
that
beric
referred
to
of
where
you
get
that
kind
of
willfulness.
If
somebody
has
deliberately
changed
something,
then
that
isn't
a
support,
because
there's
a
human
error
that
is
has
been
potentially
something
deliberate
and
that
requires
a
criminal
investigation.
B
So
I
think
it's
a
good
example
of
the
balance
that
needs
to
be
struck.
This
balance
between
regulatory
action
and
criminal
action
being
played
out,
and
so
I
think
it's
worth
tracking
the
colchester
thing
as
well.
In
terms
of
the
question
that
you're
asking
about
how
that
plays
through,
I
think
mike's
points
about.
We
will
get
more
approaches
from
whistleblowers
who
feel
emboldened
because
they
know
we're
coming
and
the
more
publicity
has
got
to
this
investigation
took
place
as
a
consequence
of
some
whistleblowing.
C
A
H
Thank
you
very
much
because
adult
social
care
is
equally
important
and
that's
what
we
got
next.
What
I
just
wanted
to
do
you've
got
the
report
and
we're
really
in
preparation
and
development
mode
around
the
new
approach
in
advanced
social
care.
So
there's
an
awful
lot
of
work.
That's
going
on
at
the
moment,
which
is
building
on
the
signposting
document,
a
fresh
start,
which
we
published
just
the
day
before
our
last
board
meeting.
H
H
So
we're.
We
are
running
a
co-production
network
group
which
met
for
the
first
time.
I
thought,
sadly,
on
the
day
that
sent
jude's
storm
blew
in
and
at
ten
o'clock
in
the
morning,
there
was
about
six
people
and
there
were
more
cqc
people
than
there
were
members
of
the
group.
But
actually
we
had
a
very
full
run
by
the
end
of
the
morning.
People
had
made
a
tremendous
effort
to
get
there
and
made
a
fantastic
contribution
and
similar
to
the
enthusiasm
that
we
were
talking
about
earlier.
H
The
second
area
is
enforcement
and
and
really
trying
to
make
sure
that
we
give
a
real
focus
to
our
work
when
we
say
that
we're
on
the
sides
of
people
who
are
using
services,
sometimes
that
means
taking
action
when
others
haven't.
You
know
it
is
absolutely
the
responsibility
of
providers
to
deliver
a
quality
service,
but
we
know,
sadly,
that's
not
always
the
case,
and
we
need
to
make
sure
that
people
can
rely
upon
us
and
again,
a
lot
of.
H
So
both
staff
and
the
external
world
can
see
how
we're
developing
this
up
and
again,
that's
generating.
You
know
quite
a
lot
of
interest
and
support,
so
something
that
I'm
committed
to
making
sure
that
we
do
so.
That
was
just
to
give
you
some
highlights
very
happy
to
take
any
questions.
I'm
particularly
interested
to
know
whether
this
is
a
structure
works
for
the
board.
G
Isn't
certainly
not
a
criticism,
but
I
just
remain
concerned
that
with
the
three
inspectors
in
the
different
sectors,
what's
being
done
about
across
the
silos
to
make
sure
that
doesn't
happen.
And
you
know
we've
seen
from
mike's
report
that
we're
looking
at
a
section
of
community
services
in
in
january.
J
H
H
We've
also
got
the
issues
of
thematic
reviews
and
and
the
and
the
focus
that
steve
will
have
on
integration
per
se,
but
I
think
that
you,
it
it
is
actually
what's
really
important,
is-
is
also
using
the
intelligence
that
we
get
from
each
other
and
steve,
and
I
you
know
we're
only
two
desks
away
from
each
other
in
the
open
plan.
So
we're
able
to
have
you
know
fruitful
conversations
about
this
early
in
the
morning,
but
you
know
it's
it's
really
important
about.
H
D
Yep,
thank
you
yeah.
I
mean
it's
very,
very
good
report
and
what
I
wondered
is
because
in
you
know,
every
year
we
we
were
required
to
to
publish
the
kind
of
state
of
care
report
and-
and
it
seems
to
me
that
there
are
kind
of
wider
issues
relating
to
social
care
that
we,
we
obviously
regulate,
services.
A
Can
I
can
I
answer
that
very
I
think
the
state
of
care
report
is
something
that
we
need
to
do
a
lot
of
thought
about
to
pick
up
the
really
big
themes
running
across
all
these
sections.
Can
we
bring
that
back
at
another
meeting
because
it's
something
we
want
to
address
early
for
next
year?
If
you
like,
do
you
mind
k?
We
do
we
do
that.
K
H
Thank
you
very
much.
Well,
I
hope
to
make
your
trip
worth
it
david
by
answering
those
questions.
The
the
issue
about
differentiation
within
we
have
behind
the
kind
of
three
main
areas
of
primary
care,
adult
social
care
and
hospitals.
17
different
types
of
service
that
we
will
be
looking
at
and
within
adult
social
care.
Domicilia
is
indeed
differentiated
from
residential
care
and
paul's
nodding
at
me.
H
H
So
again,
picking
up
steve's
point:
there's
learning
across
all
three
of
us
in
terms
of
understanding
how
we
do
that,
whether
that
means
that
people
need
to
have
different
skills,
because
we
haven't
answered
question
one.
I
can't
answer
question
two,
but
what
I
do
think
that
that
is
really
important
is
about
the
training
and
the
support
that
we
give
and
you're
absolutely
right.
The
academy
and
and
the
support
that
we're
going
to
give
to
staff
has
has
a
critical
place
to
play
there.
H
In
terms
of
the
question
about
quality
summits
and
health
watch,
we
had
this
conversation
anna
and
I
have
this
conversation
and
catherine
rake
anna's
chief
executive
at
healthwatch,
england.
We
have
this
conversation
and
we
have
the
conversation
with
respect
to
the
team
in
newcastle
last
night
as
well.
I,
for
me
healthwatch,
the
local
health
watch
are
critically
important.
H
You
know
mike
has
already
said,
he's
not
going
to
have
quite
the
same
level
of
data
available
to
him
in
advance
of
inspections
for
mental
health
services
and
community
health
services.
You
know:
try
trying
try
doing
adult
social
care
mike,
I
mean
you
know,
there's
that
we
don't
have
necessarily
the
same
level
of
data.
We
do
in
some
places,
but
it's
not
necessarily
consistent
and
it's
not
necessarily
as
robust
as
we
would
like
it.
H
So,
for
me,
the
the
insight
that
we
can
get
from
local
health
watch
will
be
really
important,
particularly
in
helping
to
direct
where
we
might
want
to
go
and
what
our
key
lines
of
inquiry
might
be
when
we
get
there,
and
so
that,
I
think,
is
an
important
thing
for
us:
the
quality
summit
it
this
one's
a
tricky
one.
We've
got
25
000
locations
to
review
in
in
in
adult
social
care.
So
the
sort
of
you
know
that
the
feedback
mechanism,
I
think,
is
going
to
have
to
be
different.
H
There
are
two
things
that
I
would
say,
though
one
is
the
immediate
feedback
and
the
way
that
we
do
that
with
the
homes
or
with
the
domiciliary
services
will
be
important,
and
we
need
to
make
sure
that
we're
working
with
local
authorities
particularly
effectively
around
this
because
they're
the
other
key
players
together
with
clinical
commissioning
groups
for
nursing
homes.
So
I
think
we
do
have
to
think
about
how
we
make
a
make
that
work,
and
the
second
thing
is
also
thinking
about
corporate
providers.
H
L
L
A
G
Thank
you.
I
I've
tried
to
lay
out
in
the
the
paper
very
simply
where
we
are.
Inevitably,
this
is
about
process
at
the
moment
at
the
next
board.
Hopefully
we
can
talk
about
some
of
the
the
outcomes
by
the
time
the
next
board
meets.
We
will
have
finalized
the
signposting
document
for
general
medical
practice
and
also
a
report
on
the
first
thousand
inspections
which
have
happened
since
april
under
the
old
system.
G
A
number
of
those
are
revisits
and
we'll
be
able
to
quantify
where
we
are
with
that
and
and
it
would
be
useful,
then
I
think
just
like
we
talked
about
colchester
to
talk
about
the
outcomes
and
the
effects
on
patients
and
how
we're
going
to
evolve
and
learn
for
the
new
system,
I'm
more
interested
in
the
outcomes
than
the
process.
I
spend
every
day
on
the
process,
but
I
would
like
to
say
something
about
patients.
G
I
I
mean,
I
believe,
I'm
here,
for
the
patients,
the
carers,
the
future
patients,
but
also
the
next
generation
and
some
of
the
things
we're
finding
in
general
practice
in
small
numbers
could
affect
the
next
generation,
not
just
the
current
generation.
For
example,
if
we're
finding
issues
which
affect
pregnant
women,
they
could
have
a
bearing
on
the
next
generation
and
therefore
they're
very
important,
whilst
hospitals
inevitably
spend.
G
Newcastle
really
reassured
me
that
we
can
really
motor
on
this
very
quickly,
but
if
we're
going
to
meet
with
local
people
at
least
every
six
months,
probably
meetings
across
the
year,
that
will
inevitably
have
an
effect
on
andrea
and
mike's
work
because
we'll
be
picking
up
information
about
social
care,
hospital
care,
mental
health
community
care
at
the
same
time,
and
I
think
we
need
a
little
bit
longer
to
consult
and
work
on
that.
So
we've
got
a
model
that
really
really
works.
G
We're
also
looking
at
starting
the
work
now
on
how
we
rate
general
medical
practices,
particularly
with
a
priority
on
elderly
vulnerable
elderly
people.
Over
the
next
six
months
or
so,
and
on
the
first
page
of
the
update
you'll
see
that
the
breadth
that
I've
got
to
sort
of
look
after
means,
we
do
have
to
prioritize
there's
some
brilliant
work
going
on
in
cqc,
which
which
often
doesn't
get
exposure.
For
example.
They
work
with
health
and
justice
and
prisons
is
really
really
good
work.
And
for
me,
because
it's
really
good
work.
G
C
Thanks
very
much
so
I
very
much
welcome
that
emphasis
on
on
on
the
user
of
service
steve,
as
you
know
so,
but
but
but
but
to
to
to
move
to
something
else.
So
you
you,
and
to
join
you
up
with
a
conversation
that
went
on
earlier
about
the
relationship
between
the
three
inspectorates
and
the
needle
is
to
keep
in
mind
the
pathways
and
the
kind
of
the
people,
the
people-centeredness
of
our
approach,
and
I
know
that
that
falls
to
you.
C
C
I
I
just
wonder
when
we
take
reports
from
the
executive,
if
we
shouldn't
be
looking
at
some
point
in
the
near
future,
to
having
not
just
the
three
reports
from
the
chief
inspectors,
but
a
fourth
report
in
into
which
all
of
the
chief
inspectors
will
need
to
feed
plus,
of
course,
paul
paul's
thematic
team,
which
specifically
addresses
those
kind
of
cross-cutting
issues
which
have
emerged
and
which
are
of
significance
to
consumers
and
users
of
health
and
social
care.
So
that
we
get
a
kind
of
broader
picture
of
of
of
what's
happening.
C
G
I
may
I
think,
that's
the
intention.
As
we
go
into
the
ccg
areas,
we
will
get
feedback
from
care
homes
from
the
hospitals,
from
gps
about
services
and
the
the
handoffs
within
a
local
area.
So
I
think
in
future
there'll
be
there
will
be
two
key
ways
of
doing
this.
One
will
be
at
locally
in
local
areas.
Looking
at
the
joins,
so
one
of
the
areas
you
might
suggest
would
be
medication
prescribing
an
administration
between
gps
and
care
homes,
which
we
know
is
a
high
risk
area.
G
Now
that
might
be
something
we
end
up
doing
just
as
a
routine
and
a
regular
piece
of
work,
but
we
should
be
looking
at
what
the
issues
are,
particularly
following
nice
guideline
production
soon,
but
there
are
lots
of
others.
Mental
health
care
crosses
general
practice.
Actually,
most
mental
health
care
is
in
primary
care,
not
in
mental
health
trusts
and
so
we're
inspecting
trusts.
G
G
The
second
issue,
which
I
think
is
really
important,
which
paul
leads
and
chairs,
which
I
think
is
entirely
appropriate,
where
we
select
as
a
board
after
consultation,
key
national
themes
that
we
can
look
at
across
the
whole
country
and
what
we've
been
doing
again.
It's
a
bit
boring.
But
it's
the
process
of
how
we
set
up
the
teams
and
the
numbers
is
to
give
some
time
so
that
all
of
our
inspectors
can
cross
all
of
the
three
inspectorates
and
be
involved
in
those
big
national
themes.
G
D
A
I
I
will
do
so.
This
covers
forms
report
and
the
finance
report
and
the
strategic
risks.
If
I
just
note
in
the
quarter
one
report,
there
was
some
erroneous
data
and
I
apologize
for
that
david.
I
think
I
sent
around
a
briefing
separately
explaining
that,
but
it
relates
particularly
to
the
quarter
one
thirteen
fourteen
figures
about
numbers
of
providers
who
have
been
non-compliant
over
long
lengths
of
time.
For
example,
we
reported
266
when
it
should
have
been
967.
I
I
So
our
enforcement
action
is
up
at
48,
more
warning
notices
than
for
the
same
quarter
last
year.
Overall,
we're
on
track
to
complete
the
program
of
inspections,
as
we've
discussed
activity
is
by
no
means
everything,
but
it's
important.
We
deliver
on
that
commitment
and
we've
deliberately
built
in
three
weeks
of
headroom
into
the
inspection
program
for
1314.,
and
each
region
is
confident
that
it
can
deliver
on
that
49-week
time
scale
and
we
are
on
track
financially
as
I'll
come
to.
We
have
a
slight
underspend
in
terms
of
the
concerns.
I
We've
not
been
able
to
improve
the
speed
of
report.
Writing.
We
have
a
metric
around
25
days
for
all
all
of
our
reports
following
inspection
and
although
that
is
relatively
close
to
that
outside
the
acute
sector,
we're
only
at
35
percent
within
the
nhs
and
that's
of
due
to
the
complexity
and
due
to
the
fact
that
we
use
more
experts
by
experience,
but
nonetheless,
it's
something
we
need
to
recover
from
and
we're
putting
recovery
trajectories
in
place
across
the
country.
For
that
our
registration
time
scales
are
also
up.
I
So
we
want
to
reply
to
everybody.
Within
eight
weeks
of
application,
we
have
seen
a
significant
uplift
in
the
number
of
applications.
One
thing
that
we
are
doing
on
that
we've
recently
moved
to
online
services
for
gp
registrations.
We
know
that's
improving
the
performance
and
we're
looking
to
roll
that
out
across
all
our
sectors
over
time.
I
But
we
have
a
plan
in
place
to
do
more
and
if
I
turn
briefly
to
the
underspend
that
6.1
million
on
forecast
and
it's
largely
driven
by
getting
additional
people
into
post
quickly
enough-
and
we
continue
to
monitor
that-
we
also
have
a
capital
underspend
and,
finally,
we're
making
sure
that
we
track
our
risks.
With
our
conversations
at
the
board
about
our
risks,
we've
added
some
more
risks
to
the
the
strategic
register,
but
we
do
believe
we
have
the
right
mitigations
in
place
for
that.
J
We
have
to
return
our
estimated
end-of-year
data
forecast
to
the
to
the
treasury
and
if
we
don't
get
it
right,
we
need
to
explain
this
to
the
treasury,
which
is
understandable.
But
my
question
is:
if
we
don't
use
the
seven
million
pound
capital,
does
that
mean
the
treasury
is
going
to
reclaim
that
so
that
we
won't
be
able
to
use
it
in
the
future?.
B
Have
we
got
plans
to
spend
this
money?
Are
those
plans
robust?
Are
the
appropriate?
Has
the
appropriate
work
being
done?
The
business
case
is
prepared,
etc,
etc,
and
there
are
capital
implications
for
the
work
we
need
to
do
that
work.
I
think
one
of
the
themes
for
today
is
just
how
quickly
we're
running
and
now
just
in
time.
A
lot
of
this
is
and
therefore
working
out.
The
precise
detail
for
things
like
capital
investments
is
is
challenging.
B
B
Again,
one
of
the
themes
of
this
morning
is,
I
think,
it's
a
bit
like
an
aircraft
taking
off
a
longer
runway.
We've
we've
gone
down
the
runway,
we're
off
the
ground,
the
trajectory
we're
gaining
height
and
I
think
we
are
going
to
as
we
bring
in
the
capability
and
capacity
going
to
end
up
spending
some
of
this
money.
B
I
don't
think
we're
going
to
spend
all
of
the
money
and
actually
I'd
be
worried
if
we
tried
to
spend
all
of
the
money,
because
what
we
need
to
do
is
make
sure
we
spend
it
on
the
things
that
we
need
to
do
so.
My
aim
is-
and
I
think
the
wording
was
quite
carefully
chosen-
is
actually
spending
this
money
appropriately,
rather
than
spending
it
and.
J
A
J
A
A
D
You
know,
because
you
know,
we've
learned,
you
know
generally
that
sort
of
targets
and
relentless
pursuit
of
targets
can
be
counter
productive,
and
so
I
you
know
if
we
don't
meet
a
performance
indicator,
you
know
I'm
not,
I
mean.
Obviously,
ideally
we
would
meet
it,
but
I
would
be
more
worried
if
we
were
sort
of
cracking
the
whip
for
our
inspectors,
who
are
working
very
hard.
You
know
to
sort
of
to
get
them
to
do
something
that
actually
is
counterproductive.
D
I
I
C
I'm
delighted
to
hear
david
say
that
we
should
never
spend
money
if
we
can't
spend
it
wisely,
brilliant,
just
just
on
on
paul's
point.
I
really
do
think
this
is.
This
is
a
classic,
isn't
it
sort
of
the
danger
of
perverse
incentives?
I
mean
we
need
to
be
defining
how
we
measure
success.
Don't
we
and
ultimately
our
success
is
not
about
how
many
warning
notices
we've
handed
out
and
it's
not
about
how
long
it
takes
to
write
the
report.
It's
about
the
quality
of
the
report.
C
Has
the
inspector
been
able
to
exercise
their
judgment?
Have
they
been
able
to
go
back
in?
Have
they
had
the
flexibility
to
go?
I
mean
I've
been
with
a
couple
of
inspectors.
I
was
shadowing
inspection
two
weeks
ago.
It
was
very
important
to
him
that
he
had
an
instinct
about
something
and
his
manager
said.
I
I
Part
of
that
is
to
lift
off
and
say
what
are
the
things
that
actually
matter
what
are
and
we've
talked
about
about
a
dozen
strategic
measures
that
are
all
linked
to
the
end
state
of
people
within
better
care,
but
track
back
from
that
about
having
rigorous
and
robust
judgments,
and
it
is
important
that
they're
timely
as
well,
and
so
we
know
this
report
isn't
exactly
where
it
needs
to
be.
We
need
to
sign
off
what
the
big
measures
are.
A
Any
any
other
business
will
we
turn
to
the
members
of
any
other
business
from
the
board
that
normally
we
would
break
for
coffee
and
meet
everyone
over
coffee.
But
if
anyone
has
got
a
burning
question
they'd
like
to
put
to
us
well,
we're
still
got
the
cameras
on
so
to
speak.
Please
do
otherwise
we're
all
available
to
talk
over
coffee.
J
Yes,
please
patient-led
assessment
is
clinical
environment
in
newcastle.
Here
I
do
both
with
someone
training.
We
are
mental
health,
hospitals,
our
newcastle,
fountain
and
there's
ordinary
trust
in
the
cutting
here,
and
we've
done
a
damn
god
hard
job
last
year,
going
like,
for
instance,
up
at
the
time,
georgia.
You
know
10
wards
not
inspect
hard
work,
all
voluntary
and
not
only
thoroughly
great
working
with
top
sisters
and
things
I'm
lead
on
the
patients
and
good
thing.
I
just
like
to
hear
it.
I
never
heard
it
mentioned,
but
we
are
equal
to
health
watch.
J
L
A
L
Day
I
cut
46
and
I've
been
complaining
about
the
hospital
not
to
write
every
time.
I
see
my
husband
and
all
the
man
there.
He
said.
Oh,
it's
good
you're
coming.
We
can
talking
the
people,
ignore
me
what,
when
the
huk
dot
yeah,
I
complain
about
it.
They
do
the
thing
right
now.
The
hospital
is
doing
very
good.
Now
ignore
that
patient.
That's
not
right.
I
mean
upstairs.
On
top
of
the
street,
the
man
was
48
tablets.
He
died
the
top
street,
they
died,
but
my
husband,
I
will
let
it
I
told
the
doctor.
L
L
L
L
The
feet
is
going
down,
I'm
very
pleased,
I'm
so
peace,
but
the
hospital
needs
to
be
better
now.
I
think
the
people
need
to
complain
about
what's
going
on,
but
the
people
didn't
say
anything
I'm
on
the
street
asking
people,
you
know
what
they
say.
My
mom
died
last
week.
100
people
died
like
that.
That's
not
right!
That's
why
I
tell
you
off
because
that
gentleman
put
a
hanno.
He
doesn't
look
like
my
granddad.
L
F
J
L
J
One
impression
you
know
I
I
I'm
an
expert
by
experience
by
the
way,
but-
and
I
came
today
to
just
to
hear
just
how
things
are
moving
on
and
they
are
moving
on.
But
I
must
say
your
administration
is
is
very,
very
bad
when
I
hear
that
you're
under
spent
by
a
budget
of
six
million
or
something
you've
got
money
that
you're
not
using.
J
You
know
the
administration
really
needs
a
good
looking
over
as
soon
as
possible,
because
you
need
the
administration
as
well
as
the
as
the
the
front
line,
and
they
don't
seem
as
if
they're
working
together.
So
please,
please
address
your
administration
as
well
as
all
the
other
things
that
you've
talked
about
today.