It has not been an easy few months for healthcare providers’ biggest regulator the Care Quality Commission. Against a background of tightened budgets, staff shortages and warnings by the Barker Commission for the need for restructuring of healthcare delivery, the CQC is facing its toughest period as a relatively new regulator.

CQC Annual Report 2015

Pitted against a constant stream of care homes closing due to financial problems brought on by cuts in local authority budgets and staff shortages and against ongoing criticism of its own performance, the CQC sought to set out its agenda in its annual report on the state of health and social care in England. The CQC found that 33% of adult social care providers required improvement, 10% were rated as inadequate for safety, with 7% (320) failing across the board. The CQC drew some comfort from the fact that the majority of people were receiving good or outstanding care, but the burning question remains on everyone’s lips, if this is the picture as the funding reduction starts, what will be the picture a few years down the line?

The CQC made clear in the report that the leading providers demonstrated what the CQC had long called for, namely, a registered manager in post for a significant period to shape the service that was provided. However, the ability for care home providers to find suitably qualified and able registered managers is easier said than done. Experienced nurses may decline the opportunity of such a role as the pressures of an Inspection and the consequences of any failure are more than many can bear.

The real problem is the recruitment and retention of staff, particularly of nurses and care support workers, which is affecting all aspects of healthcare. Trying to keep standards high when there is a high staff turnover is difficult, trying to raise standards from a low starting point with gaps in leadership positions in a care home is impossible.

CQC failed to catch up on inspection shortfall

In October 2015, the CQC announced at its board meeting that it was significantly behind the curve on its target for the number of inspections that it had set itself in the current financial year. This applied to all 3 areas: Adult Social Care, Hospitals and Primary Medical Services (GP Practices). It would seem that the CQC also had difficulty in recruiting Inspectors and was concerned about reductions in its budget. The CQC announced that it still expected to inspect every acute NHS trust in England by the end of March 2016, as well as every acute specialist, mental health, community healthcare and ambulance trust by the end of June 2016, using its robust, expert-led, and person-focused regime. However, their plans to inspect every adult soIt has not been an easy few months for healthcare providers’ biggest regulator the Care Quality Commission. Against a background of tightened budgets, staff shortages and warnings by the Barker Commission for the need for restructuring of healthcare delivery, the CQC is facing its toughest period as a relatively new regulator.

CQC Annual Report 2015

Pitted against a constant stream of care homes closing due to financial problems brought on by cuts in local authority budgets and staff shortages and against ongoing criticism of its own performance, the CQC sought to set out its agenda in its annual report on the state of health and social care in England. The CQC found that 33% of adult social care providers required improvement, 10% were rated as inadequate for safety, with 7% (320) failing across the board. The CQC drew some comfort from the fact that the majority of people were receiving good or outstanding care, but the burning question remains on everyone’s lips, if this is the picture as the funding reduction starts, what will be the picture a few years down the line?

The CQC made clear in the report that the leading providers demonstrated what the CQC had long called for, namely, a registered manager in post for a significant period to shape the service that was provided. However, the ability for care home providers to find suitably qualified and able registered managers is easier said than done. Experienced nurses may decline the opportunity of such a role as the pressures of an Inspection and the consequences of any failure are more than many can bear.

The real problem is the recruitment and retention of staff, particularly of nurses and care support workers, which is affecting all aspects of healthcare. Trying to keep standards high when there is a high staff turnover is difficult, trying to raise standards from a low starting point with gaps in leadership positions in a care home is impossible.

CQC failed to catch up on inspection shortfall

In October 2015, the CQC announced at its board meeting that it was significantly behind the curve on its target for the number of inspections that it had set itself in the current financial year. This applied to all 3 areas: Adult Social Care, Hospitals and Primary Medical Services (GP Practices). It would seem that the CQC also had difficulty in recruiting Inspectors and was concerned about reductions in its budget. The CQC announced that it still expected to inspect every acute NHS trust in England by the end of March 2016, as well as every acute specialist, mental health, community healthcare and ambulance trust by the end of June 2016, using its robust, expert-led, and person-focused regime. However, their plans to inspect every adult social care, general practice and out-of-hours primary care service in England by the end of September 2016, with their new inspection regime, were behind schedule and further planning was needed to confirm whether all independent health services could be inspected by the end of December 2016.

Providers could self-regulate under new CQC inspection strategy

In response to the challenges faced in trying to inspect so many services the CQC have outlined proposed changes to the way that it worked in its 2016-21 strategy. It suggested, in a consultation, that they could include a move to a co-regulation regime, where providers proactively assess their own quality of care and report back on changes since previous inspections.

The co-regulation focus would place greater responsibility on providers to assess and share evidence of their own quality of care against the CQC’s key questions. This could be further expanded by asking providers that have already been inspected under the CQC’s new approach to proactively report on any changes to the quality of care provided since their previous inspection.

It does not take a genius to realise the dangers of self-reporting. If you take as a starting point that all healthcare professionals believe that they are delivering healthcare that is to the best of their ability and they always have uppermost in their minds the safety of the public, yet, inspections frequently reveal that those who are trying their best and are sincere in their care, can still fail to deliver a satisfactory level of healthcare and be unaware of their shortcomings prior to inspection. Such a system could only work where the CQC have already inspected and determined that a service is good or outstanding as those who provided a lower standard of care would not necessarily recognise such in their self-reporting prior to inspection. Furthermore, a change in a registered manager of an outstanding care home can remove any assurance of a continuity of high standards. CQC intends to classify service providers based on risk from known information and use the information provided from the self-reporting to assist with smarter monitoring.

The Report of the House of Commons Committee of Public Accounts

The CQC’s appearance before the Committee of Public Accounts resulted in its current shortcomings being highlighted for all to see. The Committee recognised that the CQC had made ‘substantial progress’ since 2012 but found that ‘it is behind where it should be, six years after it was established, in that it is not yet an effective regulator.’ The report highlighted the significant impact staff shortages are having on the Commission’s ability to complete its inspection programme, and identified weaknesses in the consistency, accuracy and timeliness of its initial draft reports. The Committee was also concerned about the Commission’s ability to respond quickly and effectively to information received from service users and staff, in particular issues raised by whistle-blowers, as well as the quality of information on offer to people seeking a care provider. The Committee made recommendations to the Government of measures to address these points, as well as a framework of deadlines by which it expected to see improvement.

Meg Hillier MP, Chair of the Committee, said: “Six years after being set up the Care Quality Commission is still not fully effective. There’s too often a long gap between inspections and reports being published – and sometimes an alarming lack of attention to detail when reports are being prepared. One NHS Foundation Trust told us staff had identified more than 200 errors in a draft Commission report, including data inaccuracies. The fact these errors were picked up offers some reassurance but this is clearly unacceptable from a public body in which taxpayers are placing their trust. Recruitment at the Commission is going too slowly, meaning too many members of the public don’t have up-to-date independent information about the quality of services provided. It is vital the public is clear on what the Commission has actually inspected, and when. If the Commission is to properly fulfil its duty to taxpayers we must see improvements in the way it collects, acts upon and publishes information. At the same time it should set out a coherent plan for managing its new responsibilities. When the Commission falls short, there must be robust measures in place to enable Parliament and the public to hold it to account.”

Conclusion

No one should underestimate the difficult task faced by the CQC in trying to set, and monitor, the application of consistent standards across the major healthcare providers in England. However, with the sad inevitably of more healthcare providers likely to fail, and the public clamour for action being taken up by politicians and journalists for good reason, as the vulnerable have few others to champion their cause, the performance of the CQC will remain under intense scrutiny. There can be no doubt that the CQC will have to demonstrate absolute control of its remit swiftly, that it can deliver inspections on time, show that standards are rising, and inspections must identify failings before disasters occur. The politicians hold the CQC’s future in their hands. Currently, the politicians are not in the mood for reform, with the CQC being relatively new. This may change by the end of this Parliament, if there are further high profile failures of providers, the politicians may then look for scapegoats prior to an election.cial care, general practice and out-of-hours primary care service in England by the end of September 2016, with their new inspection regime, were behind schedule and further planning was needed to confirm whether all independent health services could be inspected by the end of December 2016.

Providers could self-regulate under new CQC inspection strategy

In response to the challenges faced in trying to inspect so many services the CQC have outlined proposed changes to the way that it worked in its 2016-21 strategy. It suggested, in a consultation, that they could include a move to a co-regulation regime, where providers proactively assess their own quality of care and report back on changes since previous inspections.

The co-regulation focus would place greater responsibility on providers to assess and share evidence of their own quality of care against the CQC’s key questions. This could be further expanded by asking providers that have already been inspected under the CQC’s new approach to proactively report on any changes to the quality of care provided since their previous inspection.

It does not take a genius to realise the dangers of self-reporting. If you take as a starting point that all healthcare professionals believe that they are delivering healthcare that is to the best of their ability and they always have uppermost in their minds the safety of the public, yet, inspections frequently reveal that those who are trying their best and are sincere in their care, can still fail to deliver a satisfactory level of healthcare and be unaware of their shortcomings prior to inspection. Such a system could only work where the CQC have already inspected and determined that a service is good or outstanding as those who provided a lower standard of care would not necessarily recognise such in their self-reporting prior to inspection. Furthermore, a change in a registered manager of an outstanding care home can remove any assurance of a continuity of high standards. CQC intends to classify service providers based on risk from known information and use the information provided from the self-reporting to assist with smarter monitoring.

The Report of the House of Commons Committee of Public Accounts

The CQC’s appearance before the Committee of Public Accounts resulted in its current shortcomings being highlighted for all to see. The Committee recognised that the CQC had made ‘substantial progress’ since 2012 but found that ‘it is behind where it should be, six years after it was established, in that it is not yet an effective regulator.’ The report highlighted the significant impact staff shortages are having on the Commission’s ability to complete its inspection programme, and identified weaknesses in the consistency, accuracy and timeliness of its initial draft reports. The Committee was also concerned about the Commission’s ability to respond quickly and effectively to information received from service users and staff, in particular issues raised by whistle-blowers, as well as the quality of information on offer to people seeking a care provider. The Committee made recommendations to the Government of measures to address these points, as well as a framework of deadlines by which it expected to see improvement.

Meg Hillier MP, Chair of the Committee, said: “Six years after being set up the Care Quality Commission is still not fully effective. There’s too often a long gap between inspections and reports being published – and sometimes an alarming lack of attention to detail when reports are being prepared. One NHS Foundation Trust told us staff had identified more than 200 errors in a draft Commission report, including data inaccuracies. The fact these errors were picked up offers some reassurance but this is clearly unacceptable from a public body in which taxpayers are placing their trust. Recruitment at the Commission is going too slowly, meaning too many members of the public don’t have up-to-date independent information about the quality of services provided. It is vital the public is clear on what the Commission has actually inspected, and when. If the Commission is to properly fulfil its duty to taxpayers we must see improvements in the way it collects, acts upon and publishes information. At the same time it should set out a coherent plan for managing its new responsibilities. When the Commission falls short, there must be robust measures in place to enable Parliament and the public to hold it to account.”

Conclusion

No one should underestimate the difficult task faced by the CQC in trying to set, and monitor, the application of consistent standards across the major healthcare providers in England. However, with the sad inevitably of more healthcare providers likely to fail, and the public clamour for action being taken up by politicians and journalists for good reason, as the vulnerable have few others to champion their cause, the performance of the CQC will remain under intense scrutiny. There can be no doubt that the CQC will have to demonstrate absolute control of its remit swiftly, that it can deliver inspections on time, show that standards are rising, and inspections must identify failings before disasters occur. The politicians hold the CQC’s future in their hands. Currently, the politicians are not in the mood for reform, with the CQC being relatively new. This may change by the end of this Parliament, if there are further high profile failures of providers, the politicians may then look for scapegoats prior to an election.