The Care Quality Commission’s recent launch of their new draft strategy ‘Changing regulation to improve care for all: our new strategy for 2021 and beyond’ was closely watched by all those involved in providing health and social care. The strategy focuses on four key themes: ‘People’, ‘Smart’, ‘Safe’ and ‘Improve’. There is a lot to welcome in the document, but also some things that are missing. Most of all, it demonstrates the difficulty of measuring quality accurately and fairly.
Taking each theme in turn, a focus on the people using services and having regulation being driven by what people expect and need has to be the right direction of travel. I do wonder, however, the extent to which there will really be a change to the focus on ‘box ticking’ rather than outcomes during inspections. Until recently, I was ’nominated Individual’ for 360 services.
I would quite regularly see more mediocre services getting a ‘good’ because they ticked all the boxes, like infection control, staff training and supervision, even though the people being supported were having humdrum lives, whilst innovative services that were pushing the boundaries, really listening to people and helping them have great lives, would get ’requires improvement’ for some relatively minor infringement.
The most extreme example I can remember, was a great supported living service that was achieving some fantastic outcomes with a complex and challenging young woman. There was an incident in the service; we weren’t sure whether it warranted a safeguarding alert, but because we believed in transparency, we contacted the local Safeguarding Team to ask their opinion.
They thanked us and said that it didn’t meet their threshold. When CQC inspected, we received a ’requires improvement’ for safe because we hadn’t sent them a notification about the safeguarding. That’s because the Safeguarding Team said that it hadn’t constituted a safeguarding. As far as CQC were concerned, just contacting the Safeguarding Team required a notification to them.
The section on people also goes on to say that registration should be driven by what people expect and need from services, rather than how providers want to deliver them. Again, a sentiment with which I wholly concur. My only comment is that there needs to be some recognition by CQC of the practicalities of designing and building new services. In the learning disability sector, the ‘Registering the Right Support’ policy has been very contentious.
There is a widespread opinion in the sector that the uncertainty the policy has caused for providers has directly led to a reduction in the number of new services opening, particularly for people with very complex and challenging needs. That in turn has been a major contributory factor in the failure of the Government’s ‘Transforming Care’ policy to reduce the number of people with learning disabilities living in hospital. People can’t leave hospital if there’s nowhere for them to go. Building-based services are expensive and have a long lead-in time. Those paying for them need assurance that revenue funding is available for the long-term. I’m not sure that CQC have demonstrated sufficient understanding of the commercial realities of running services, probably because the majority of regulators have never had that experience.
The section on Smart talks about the use of data to enable CQC to take a more intelligent approach to assessing the quality of services. I wholly support that direction of travel and there are a number of brilliant products on the market, some developed by providers, which mean that there is access to a huge variety of information to inform the assessment of quality. CQC says that it will reduce its reliance on the inspection of services. My only comment here, as someone who visited 10 services a week regularly for over 20 years, is that you do get a sense of the ethos and culture of a service by stepping over the threshold. Sometimes you will get a gut feeling that things aren’t quite right, even though you might struggle to work out why. That soft intelligence is essential and we shouldn’t lose it in a drive to use data more intelligently.
The discussion of Safe makes a lot of sense and I endorse CQC’s emphasis on a transparent and open safety culture. My main critique here is that the document doesn’t talk more broadly about organisational culture. Openness and transparency don’t just flow from a safety culture, they reflect the overall culture of the organisation and crucially how it is led. The document makes the point that the NHS has a National Patient Safety Agency to ensure that there is a culture of learning and sharing lessons from other organisations which doesn’t exist in other health and social care sectors, leading to greater fragmentation. I completely agree with that and, as the Chief Executive of a large care provider, I was struck that there was no mechanism to learn lessons from other organisations about things that may have gone wrong.
All large organisations, unfortunately, have serious incidents from time to time, like people being scalded, drowning in the bath, chocking and having falls. Apart from anecdotal conversations between chief executives and other senior managers from different organisations, there is no current mechanism for sharing experiences and learning lessons. The sector would certainly benefit from a more structured approach.
The main thing missing from the strategy in my view is any reference to leadership and culture. We all know how crucial leadership is in ensuring that organisations value and support their staff and focus on listening and responding to the people they support. I like the ’well led’ review process that CQC operates with NHS providers. I certainly think there should be much more focus on the leadership and culture of social care providers, rather than simply looking at the performance of individual services. I was ‘nominated individual’ with CQC for many years.
No one from CQC ever checked up on my personal development, asked me how often I visited services or questioned how the organisation’s Board ensured effective oversight of quality and safety. Unless the new strategy addresses this crucial area, it will be an opportunity missed.
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