Caring Times: How many new starts does CQC require?

At Ridouts we have seen an increasingly aggressive CQC emerging over the last year.  It is not holding back when it comes to taking enforcement action against providers it deems to be non-compliant with the law.  However, in our experience, whilst the CQC is determined to push forward fervently against providers, the case the CQC present to justify its action is often weak, lacking in substance and in some cases just plain wrong.  There is huge disparity in approach between inspectors and regions despite the Essential Standards being introduced to unify a system of differing requirements for different services.

At the June 2013 Health+ Care event at the Excel Centre, London, the CQC’s new Director of Strategy and Intelligence, Dr Paul Bate described the current model of inspection as “broken” and in respect of the Grant Thornton Report commissioned by the CQC into University Hospitals Morecambe Bay NHS Foundation Trust, the CQC’s Chair, David Prior told the BBC on 19 June 2013 that CQC  “were not fit for purpose at all when it came to hospital inspections” – both honest assessments but this will hardly instil confidence in those providers currently facing scrutiny by the CQC.

On 17 June 2013, the CQC launched a consultation paper called “A new start” which is seeking people’s views on proposed changes to the way CQC regulates, inspects and monitors care.  The consultation closes on 12 August 2013.

Some of the key changes the CQC is seeking to make are as follows:

  • CQC has recognised that inspectors can no longer be generalists but rather expert teams will be led by Chief Inspectors of Hospitals, Social Care and General Practice.  Speaking to the BBC on 19 June 2013, David Prior stated that the CQC had been giving assurances to the public which were not backed up by expert inspectors.
  • A rating system will be re-introduced in 2014/2015 to “become the single, authoritative assessment of the quality and safety provided by an organisation”.  The ratings that will be given are:
    • Inadequate
    • Requires improvement
    • Good
    • Outstanding

The consultation paper notes how the ratings will work in relation to NHS acute hospitals.  It indicates that all five questions will be treated equally.  You will recall that the old care home star ratings gave additional weight to particular aspects which would cap your overall rating – a fundamental flaw of that system.

The ratings will dictate the frequency of inspections just as we previously had.  In respect of NHS acute hospitals (which is likely to give some indication of approach with other service types) the consultation notes that the CQC will inspect Outstanding hospitals every 3-5 years; Good hospitals every 2-3 years; hospitals which Require Improvements at least once a year and Inadequate, as and when needed.  One of the criticisms arising out of the Winterbourne View scandal was that the CQC had moved from regular inspections to a light-touch approach, relying on self-regulation.  In response to Winterbourne CQC moved back to yearly inspections.  Many people believe that visits are the only way to see what is actually happening, although as we have recently seen, via the Grant Thornton Report, sometimes, even when CQC see what is happening they do not take necessary action. Now it would appear that it is seeking to return to non-frequent visits to services.  Whilst this means that extremely long periods of time could pass between inspections when standards could fluctuate significantly, CQC have also stated that it will be “re-thinking” and “redesigning” how they use information they receive to help direct its regulatory activity.  We’ll have to see what this actually entails.

  • 5 key questions will be asked about each service and a judgement made at each inspection:
    • Is it safe?
    • Is it effective?
    • Is it caring?
    • Is it responsive to people’s needs?
    • Is it well-led?

CQC will move away from saying whether providers are “compliant” or “non-compliant”.

  • Embracing recommendations from the Francis Report CQC will develop what may be described as a three tier level of care standards – Fundamentals of Care; Expected Standards and High-quality Care:
  • The Fundamentals of Care will be standards below which no provider will be expected to fall.  These will be the most basic care provision.  Where a provider fails to provide the fundamental levels of care it can be prosecuted without being given a warning to put the failure right first.  These will be tied into the legal requirements of registration.
  • The Expected Standards will be standards service users can expect as a matter of course.  It is not clear how, in practice, the Expected Standards differ to that of the Fundamentals of Care, except as noted above the Fundamentals will be linked to the relevant legislation whereas the consultation makes no reference to this being the case in relation to Expected Standards.  CQC will consider whether any of the current Essential Standards can be mirrored in the Expected Standards.
  • The CQC will look to other organisations such as NICE to determine what High –quality Care standards look like.
  • A statutory “duty of candour” as a CQC registration requirement will be introduced which requires providers to tell service users and their families when things go wrong and explain why.  If the provider fails to be open then CQC could prosecute without issuing a warning notice first.
  • Directors and leaders will be held personally accountable for ensuring their organisations provide safe, high-quality care.  If they fail to honour this commitment they could be removed from their position.

The Department of Health is due to publish a consultation papers regarding holding providers to account which will include board directors being subject to a fit and proper person test.

CQC has re-invented itself and its processes before but still cannot seem to get it quite right.  With more and more scandals emerging from the woodwork, where it is in some way implicated, CQC are going to have to do something significant to assure the public that its stated purpose “to make sure health and social care services provide people with safe, effective, compassionate, high-quality care” can be achieved.  It is not surprising that some people are sceptical about whether this will happen.

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