CQC Board Meeting 7th February 2024 - Wednesday 7 February 2024, 1:30pm - Transcript Tab - Care Quality Commission

CQC Board Meeting 7th February 2024
Wednesday, 7th February 2024 at 1:30pm 

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  1. Ian Dilks
  2. Elin Sams
  3. Ian Dilks
  4. Mark Chakravarty
  5. Ian Dilks
  6. Charmion Pears
  7. Ian Dilks
  8. Mr Ian Trenholm
  9. Ian Dilks
  10. Chris Day
  11. Prem Premachandran
  12. Ian Dilks
  13. Christine Asbury
  14. Christine Asbury
  15. Ian Dilks
  16. Ian Dilks
  17. James Bullion
  18. Ian Dilks
  19. Mark Chakravarty
  20. Ian Dilks
  21. James Bullion
  22. Ian Dilks
  23. Prem Premachandran
  24. Chris Day
  25. Ian Dilks
  26. Prem Premachandran
  27. Ian Dilks
  28. Mark Chakravarty
  29. Ian Dilks
  30. Stephen Marston
  31. Ian Dilks
  32. Mr Ian Trenholm
  33. Ian Dilks
  34. Elin Sams
  35. Ian Dilks
  36. James Bullion
  37. Ian Dilks
  38. Mr David Croisdale-Appleby
  39. Ian Dilks
  40. Christine Asbury
  41. Ian Dilks
  42. Mr Ian Trenholm
  43. Ian Dilks
  44. Chris Day
  45. Ian Dilks
  46. Chris Usher
  47. Kate Terroni
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  1. Chris Usher
  2. Ian Dilks
  3. Belinda Black
  4. Ian Dilks
  5. Tyson Hepple
  6. Ian Dilks
  7. Stephen Marston
  8. Ian Dilks
  9. Chris Usher
  10. Kate Terroni
  11. Chris Usher
  12. Chris Day
  13. Ian Dilks
  14. Tyson Hepple
  15. Ian Dilks
  16. Mr Mark Sutton
  17. Ian Dilks
  18. Mr Mark Sutton
  19. Ian Dilks
  20. Mark Chambers
  21. Ian Dilks
  22. Tyson Hepple
  23. Ian Dilks
  24. Stephen Marston
  25. Ian Dilks
  26. James Bullion
  27. Ian Dilks
  28. Mark Chambers
  29. Ian Dilks
  30. Mr David Croisdale-Appleby
  31. Ian Dilks
  32. Presenter 2
  33. Ian Dilks
  34. Belinda Black
  35. Presenter 2
  36. Presenter 1
  37. Ian Dilks
  38. James Bullion
  39. Presenter 2
  40. Presenter 1
  41. Ian Dilks
  42. Chris Day
  43. Ian Dilks
  44. Tyson Hepple
  45. Presenter 2
  46. Presenter 1
  47. Ian Dilks
  48. James Bullion
  49. Presenter 2
  50. Ian Dilks
  51. Ian Dilks
  52. Presenter 1
  53. Presenter 1
  54. Mr David Croisdale-Appleby
  55. Ian Dilks
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  1. Ian Dilks
  2. James Bullion
  3. Presenter 2
  4. Ian Dilks
  5. Presenter 2
  6. Ian Dilks
  7. Ian Dilks
  8. James Bullion
  9. James Bullion
  10. Ian Dilks
  11. Mr Mark Sutton
  12. Ian Dilks
  13. Mark Chambers
  14. Ian Dilks
  15. James Bullion
  16. Mark Chambers
  17. Ian Dilks
  18. Stephen Marston
  19. Presenter 2
  20. Ian Dilks
  21. Ali Hasan
  22. Ian Dilks
  23. Presenter 2
  24. Ian Dilks
  25. Chris Usher
  26. Kate Terroni
  27. Ian Dilks
  28. Elin Sams
  29. Ian Dilks
  30. Chris Usher
  31. Kate Terroni
  32. Ian Dilks
  33. Joyce Frederick
  34. Ian Dilks
  35. Christine Asbury
  36. Ian Dilks
  37. Stephen Marston
  38. Joyce Frederick
  39. Ian Dilks
  40. Tyson Hepple
  41. Ian Dilks
  42. Mr Ian Trenholm
  43. Ian Dilks
  44. Mark Chakravarty
  45. Ian Dilks
  46. Mark Chambers
  47. Ian Dilks
  48. Mr Jeremy Boss
  49. Ian Dilks
  50. Mark Chambers
  51. Ian Dilks
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  1. Chris Day
  2. Ian Dilks
  3. Chris Day
  4. Ian Dilks
  5. Chris Day
  6. Ian Dilks
  7. Tyson Hepple
  8. Ian Dilks
  9. Webcast Finished

1.0 Opening matters

Mr Ian Dilks - 0:00:00
And to those dialling in, welcome to the public Board meeting of the Care Quality Commission on 7th of February 2024. Thank you for joining us. I have a number of introductions or welcomes to do. Firstly, I believe everyone on screen can see, but can
I introduce Charmion Pears over in the corner who joined us on the 1st of February, so still brand-new, and will take over, has taken over as the Chair of the Audit and Risk Assurance Committee. We have had a number of new non-executives join us
over the course of the last few months. Under our regulations they have to outnumber the executives, but bringing more people on to the board has meant that we have been able to appoint some of the Executive Team to the Board as well. So, I
would like to welcome – the faces you are all familiar with – Tyson Hepple, James Bullion and Mark Sutton, existing members of the Executive Team, but now formally joining the Board, so welcome colleagues. We have apologies from one board member Sean O’Kelly who, unfortunately,
is still ill. Our commiseration for the illness, but delighted that Prem Premachandran who works on the team is with us. I know you are shouldering a lot of responsibility in Sean’s absence, so thank you for joining us today. The last person I will introduce
is Elin Sams. Elin, she is the Chair of our Gender Equality Network representative and Elin, it might just be helpful if you’d say a few
Elin Sams - 0:01:39
seconds on why you have joined us. Thank you very much. Yes, thank you for allowing me to join today.
I am here representing all the Equality Networks, so I am one of the Co-Chairs of the Gender Equality Network, but it is also the (unintelligible) Disability and Carers Networks. So, thank you for allowing me to be here. It is just a really excellent opportunity
really for us to highlight seldom-heard voices or under-heard, voices, and also it allows me to provide a bit of a nuanced perspective or questions based on things that, you know, we are hearing from an equality perspective, so thank you very much.
Mr Ian Dilks - 0:02:15
Thanks very much Elin. It is, I find
it increasingly useful as a sort of conduit to the wider population of our people to the Board, so thank you for that, and indeed your other colleagues who have joined us in other meetings. Declarations of interest, I know there are a couple of things
for the record we should note. Mark, I might start with you. Thank you
Mark Chakravarty - 0:02:37
very much. Just a new declaration of interest, as of January I started as an adviser to Archetype which is a venture fund based in the US. I don’t think there is
Mr Ian Dilks - 0:02:45
any direct issue there, but thank you and Charmion. Thank you, I
Charmion Pears - 0:02:52
should advise that I am an independent member of the HSE Health and Safety Executive’s Audit and Risk Committee. If there was ever any items that involve both organisations, the HSE and CQC, I
would bring this conflict to the attention of the Board. Secondly, my husband is a non-executive on a housing organisation in Cornwall where a small part of that business is extra care accommodation regulated by the CQC. Again, if there was ever to become a topic
that was discussed at the Board, I would recuse myself from that
Mr Ian Dilks - 0:03:26
conversation. OK, thanks Charmion. I mean the first thing mentioned, I see as a mutuality venture rather than a conflict, but better to have that recorded. And for the avoidance of doubt, that role
your husband has, it was looked at, the Department of Health signed it off as a not an issue on your appointment. I was also consulted and I think, in the highly unlikely event that we ever at this Board discuss anything that could seemingly impact
your husband’s role, then obviously you would need to recuse yourself. Although as I say it is unlikely, but thank you for declaring it. Is there any urgent business? We have an agenda in front of us, quite a full agenda, is there anything else people
want to put on it before we start? It looks like not. The first item on the agenda is the update from the Executive. I would say we would allow 20 minutes for that, but actually, since the agenda was put together, there is an awful
lot on that agenda. Ian, as part of your opening remarks, you might also pick up one thing that’s not here which is the work we have recently asked to undertake in Nottingham. I think that would be of interest both to the Board and to
people listening in. So I’m going to allow about half an hour for this first session, if we try to keep to that. Apologies if that means we run over at the end. I’ll try not to now, but just warning in advance that I think
for those extra points, we may just run over slightly at the very end.
Mr Ian Trenholm - 0:04:53
But Ian, over to you. Thanks very much Ian and good afternoon everybody. As you said, quite a lot going on at the moment. So if I do what I normally do
and take this paper and the next paper in one go, and then we can come back with questions after that. So, kicking off on Regulation 9A on visiting, many of you remember, particularly during COVID, there was a very important public conversation around the right
to visit, the right to be accompanied by people when you are either resident in a care home, going to a hospital, or indeed in a hospice. In the latter part of last year, government set out a new regulation, Regulation 9A relating to visiting. It
is worth stressing, it is care homes, hospitals and hospices, it is not just in social care settings. It is designed to ensure that people have visitors and can be accommodated by advocates, even in these fairly complex environments. But whenever there is a new regulation
published, we need to guidance to accompany that new regulation. So, we are consulting now on that guidance and that consultation is open until the 20th of February. It is worth stressing, this is not a consultation on the regulation itself, that was carried out by
the Department of Health and Social Care last year. This is about the guidance component of it, the CQC component. So, I guess I would appeal to any members of the public, or any providers who are listening in, if they want to comment on our
guidance, then they have until the 20th of February to do so. Moving on to the next page, we are commencing work on a dementia strategy. We have as part of our purpose, the need to regulate providers and to promote improvement, this is something we
take very seriously. We have seen in other areas like maternity services or mental health, when we look across the country and look at themes we can make a bigger difference if we have a thematic approach to some sorts of services, and that, therefore, makes
improvement much more structured. We feel that given the impact of dementia on so many of the people that are being looked after in those that we regulate, and indeed sometimes in terms of how it impacts on us internally, that both in terms of health
and social care - it is important to stress this is not, again, not just a social care issue - that it would be really worthwhile having a dementia strategy. We can make sure that we can learn lessons from that strategy and then embed them
into our Single Assessment Framework. So that, when we are regulating on a regular basis, we can link directly back to this dementia strategy. So, work is ongoing and James can talk a little bit more about that if colleagues would like. Moving on to the
National Maternity Programme, you will be aware that we carried out a maternity programme over the last 18 months or so, so we have a post-COVID view of every maternity service in the country. The fieldwork was completed in December and we are now just writing
up those individual provider reports. The last few are being written up. We are also going to be doing a summary report from which will spin off a number of other products, and some of that will be about creating products that individual practitioners are using
in terms of identifying good practice and making sure that we can find ways to embed that good practice into our own regulation, but also encourage all providers to try and be as best, as good as the best in terms of maternity. So we know
that it is a particularly important area of work and it is something that over the next couple of months, you will start to see the summary reports coming through. I wanted to move on and talk about Martha’s Rule. Martha Mills, sadly, died in 2021
after having developed sepsis at King’s College Hospital. A coroner ruled last year that Martha would most likely have survived had her doctors moved her to an intensive care and listened to the concerns, particularly those that were expressed by her mother about the case. The
Patient Safety Commissioner, Dr Henrietta Hughes, has been asked to develop a set of recommendations for a Martha’s Rule in England, enabling families to request a clinical review of the care that they are receiving. The scheme is based on practice in both Australia and some
parts of the UK as well. We have been part of the work all the way through this, and the work is proceeding quite deliberately at pace, and our engagement is being led by our colleague Joyce Frederick, and the aim is to embed Martha’s Rule,
the requirements of Martha’s rule, again into our Single Assessment Framework, so it becomes an integral part of the way that we regulate. Moving on to organisational matters, we are… we want to… I have got to…, well, I am pleased to have both Prem and
Chris in the room today. They will be talking about managing risk in the NHS during winter in a little bit more detail in a second, but I think the headline is that we have continued to ensure that we work in a proportional way over
the winter period balancing the needs of the public with those of those delivering services under very significant pressure. I think we do need to acknowledge the significant pressure that both health and care system have been under over this last winter period, but also recognising
the impact that has on the public and our role as a regulator trying to navigate between those two, those two important perspectives. This year we have used the work that we have refined over the last couple of years that was very much led by
Prem and colleagues in the Royal College of Emergency Medicine. We have refreshed it, but we have also again embedded that within our Single Assessment Framework, and I think that has been the new thing this year is that we have been able to make sure
that, as part of our regulatory work, there is clear regulatory value being derived from that work and Prem can talk a little bit more about that in a second, exactly what that means. We have been also working closely with the regular NHS groups that
manage winter to make sure that there is an effective escalation point, we understand when things are going particularly badly in some areas, and we can support appropriately. Moving on to the Thirlwall inquiry, we know that, in terms of the Thirlwall Inquiry, we have received
a formal request for information and we have been designated as a core participant in relation to the work that we did in regulating the Countess of Chester Hospital. Our first drafted statement has been submitted and will be finalised and formally submitted as a final
statement in the next few days. That largely covers the background to what we do as an organisation and our methodology during the period under review of the inquiry. The second part of our submission will be a second statement and that will cover the more
detailed issues of exactly when we went in and who we spoke to and so forth, that more detailed, specific inspection dimension of our inspections of the Countess of Chester Hospital. We expect hearings to start in the autumn, we will obviously be giving evidence at
that point. In terms of the COVID-19 Inquiry, we have submitted our application to be a core participant for Module 6 which covers the Care sector. You will recall that we have submitted evidence for earlier modules where we were not a core participant. We took
advice from the Inquiry and, and it wasn’t deemed appropriate. Being a core participant is a positive in the sense that it enables us to have greater range of access to material than the average member of the public would have. But it does also mean
there is a significant amount of work and a significant expectation that if we have got access to the material we have read it, analysed it and, again, we are proactively responsive to the information that other people are offering. In terms of technology, there is
couple of pieces in the report around technology. A significant amount of focus at the moment, as you would expect, on the transition from the project part of the future regulatory platform through to making it a live service, and that is taking up a lot
of the time of both the programme team, but also Mark Sutton and his group. I just want to record an enormous thank you for a number of colleagues who have been involved in that. Oftentimes we just see this stuff happened seamlessly, it very much
doesn’t happen seamlessly, so an enormous thank you to my technology colleagues for the great work they have been doing in that area, alongside colleagues from the programme, some of whom will be with us later on. We will be launching our new intranet shortly. Whilst
there is a big technology component to the new intranet, there is also a significant component around refreshed content. Again, Chris and his team have been working incredibly hard to refresh the content of the intranet. The intranet in this organisation is a really important tool
for inspectors to access quickly guidance and other information, and so we want to make sure that it is as accessible and as up-to-date as it possibly can be, and the ability to search for things quickly is there and hence the work that has gone
on recently. Data and Insight, the data and insight team have been working hard as we have gone live with the Single Assessment Framework. Over the last few weeks they have been looking at how the data we have been collecting can be rendered in a
way that is accessible to individual managers, individual decision makers and policymakers to make sure we are making the best possible use of the data that we are collecting and that we are creating new dashboards relatively quickly. It is one of the kind of unspoken,
unsung benefits, I think, of the system is the ability to take data and very quickly render that in ways that it can be used for a range of different purposes which is really positive. And finally, as Ian invited me to just talk about where
we are in relation to work in the Nottinghamshire area, around mental health trusts. You will know in the last few days the trial of Mr Calocone concluded after he pleaded guilty to three counts of manslaughter with diminished responsibility. The Secretary of State has asked
us to carry out a so-called Section 48 review, Section 48 of the Health and Care Act. And what that does is it enables the Secretary of State to ask us to carry out a piece of thematic work to look at events or themes across
the area that we would normally regulate in. So we are doing…, we have been asked by the Secretary of State to look at a couple of things. One is to look specifically at Mr Calocone’s care, as well as to look at the care that
other people with similar health conditions have received from the same trust. We have also been asked to provide some specific advice around the relicensing of the Rampton Forensic Secure Facility. Rampton is one of the three forensic secure mental health hospitals in this country and
has some specific role to play around women who have been detained, but also people who are deaf, so it has some very unique, a very unique role in the country. We have been asked to do this work at some pace. We have got colleagues
who are on site doing work now and we are expecting to report to the Secretary of State in the early part of March for her to make a decision around Rampton’s relicensing and we will be doing case reviews during that period as well. Thanks
Mr Ian Dilks - 0:16:55
Ian. A huge amount there. I am not going to attempt to take the items one-by-one. I think we should leave it to colleagues to ask questions. Just wondering, would it be helpful - there is a lot in here about winter planning, would it be
helpful just to dive straight to that on the grounds that we’d like to know more? So, Chris and Prem, can I hand it to you? Just to say don’t repeat the papers. We have read the papers, but what do you want to highlight because
it is an important issue? Sure. Just to begin before I hand over to
Chris Day - 0:17:22
Prem. As Ian said, this is about trying to understand and assess risk, and what we know is it is a very difficult time. We have also been providing advice and support on good practice, and particularly
in light of our work on Patient First and People First, focusing on a system response, we know that issues that operate in urgent and emergency care don’t all have their origins in urgent and emergency care. So, some of the support we have been providing
is around the system context in different areas. I will hand over to Prem, our national professional advisor for urgent and emergency care in a second, but just to say, also, our approach has not just been to focus on urgent and emergency care, but also
focus on building capacity in social care. So, part of the work we have been doing - we know that there is still strong pressure in adult social care - so focusing on building capacity through our re-inspection of services, particularly prioritising registrations and re-inspections of
services that are “requires improvement” to get them to “good”. We know that with that “good” rating, they are more able to take on further work. So, I am just going to hand over to Prem because I think Prem can talk through - obviously Prem,
as you know, is a national professional advisor, but also works at an outstanding trust at Frimley - has got some really, I think, some really interesting insights into the work so far. We will aim to publish a full report on what we have found
over the winter period to guide our own thinking in terms of system reviews, but also to help and support trusts as they make those difficult decisions around risk, but, Prem, I wonder if you want to say a bit more about that? Thank you Chris.
I think what I will do is I will give you some overview of the current
Prem Premachandran - 0:19:08
situation and what is CQC’s response to the winter pressure, and the new Single Assessment Framework, how it actually transforms the objective way of assessing aidees. I think the first
point I want to make is this winter is no different to any other winter. I think in order to understand the problem, I think we need not only to look at the data, but also listened to patients, staff, and also along with the culture
and leadership because they make a big difference. I think staff work very hard in the service at the moment, in very difficult circumstances. There is no respite in the NHS winter. and also there is a major spike in winter viruses, flu, COVID, norovirus. So,
that is piling up the pressure on NHS service. So what is the problem with that, actually it is its impact on quality and safety of patient care, surgeon ambulance call out handover delays, crowded emergency departments, increased corridor care, lack of social care beds. These
pressures are being compounded by worrying level of staff sickness as well in this winter. So, these are all causing small problems, but I must say, despite the changes some trusts have made some improvements, better than the others, by doing successful virtual wards, so reducing
the number of admissions. Same day emergency care. And also other important thing is collaborative working and also risk sharing make a big difference in some places doing better than the other places. I think, as we know, the only solution to the current problem is
a whole system approach. That’s the only way to solve the problem. The problem actually is like a block in one part of the system, causing serious problems to completely different to the other system. Particularly, there is a gap between the health and social care,
so that is actually, as Chris mentioned, it is a big problem. And also there is the trusts almost working as a series of small islands rather than working together. And also there is, we talk about, yes, there are 120,000 staff vacancies, but there is
a lack of teamwork and in some of the places, complacency and normalisation of certain culture and practice. That is making the situation worse. So, CQC are committed to system-wide change to emergency care. So, this in line with the response to winter pressure, we are
committed to work with providers – it is really important - and system partners and also the major stakeholders, particularly NHS England, to fulfil our role to make sure that social care service provide and also the health provide people with safe, effective, compassionate, high-quality care.
So I think what we have done this time, actually because of the change in our process, we are using, as Chris already mentioned, using the Patient First and People First documents to support the system to mitigate some of the problems. Also as an organisation
we want to appreciate the system is under a lot of pressure, so we don’t want to increase the pressure by doing some very intense inspection to assessment. So, we are very aware of that. We have frequent conversations with external stakeholders like NHSE regarding our
approach to the problem. We use previous winter’s called Pressure Resilience 5, so this time what we have done is we have mapped the Pressure Resilience 5 to Single Assessment Framework and we are going to trial that in different parts of the system to see
how it works. I think I am very confident this new form of Single Assessment Framework will make a better understanding of the problem and a more objective and transparent approach. I also think it is not this time…, the inspection is not going to be
just emergency departments, but we want to look at the whole system and how they are approaching the risk as well. There is a good example of this approach in the East of England. It recently made a significant improvement in mitigating safety issues in the
system. Also, I just want to finally, before asking for some questions, in order of the magnitude, things go more right than wrong actually. So, sometimes we spend a lot of time looking at the wrong things, but it is important not to lose sight of
the good things people are doing and appreciate even. There are staff doing amazing things, often in very difficult circumstances. So I think OK, there are difficult situations in the winter, but there are pockets of good practice as well. I think we need to recognise
Mr Ian Dilks - 0:24:54
that as well. I will stop there for questions. Thanks Prem, for acknowledging the good practice as well, it’s so easy to overlook. Questions on any of the 300 subjects we have just covered? Christine.
Ms. Christine Asbury - 0:25:10
Thank you. More of a sort of comment really about the dementia strategy. Are you ready to talk about that? So
Mr Ian Dilks - 0:25:15
Ms. Christine Asbury - 0:25:15
first of all, I am very pleased that we are focusing on a dementia strategy, I think it is very important. I am also really pleased that it’s cross-sector, so it’s also health, because my belief is that health lags behind social care. But then I
really just wanted to reiterate a couple of points, one is the importance of genuine co-production which really does involve a wide group of people and is not a sort of afterthought. And the second is to ensure that we look at innovative practice that is
already out there, particularly innovative providers where there is a lot to learn, particularly from social care. And by innovation, I
Mr Ian Dilks - 0:25:57
don’t mean technology, I mean actual practice. That saves me asking the question I was going to ask, so thank you for that. James, do
you want to respond? Well, thank you and good afternoon, and thanks to
Mr James Bullion - 0:26:05
Christine for raising the issue. It is really important that the dementia strategy begins with the aim of us improving regulation and starting with the key question that is outlined in the paper
about what is people’s experience and what is the experience of carers? Part of the rationale, therefore, is to work up the strategy in a way that allows us to build a really good picture of what good looks like, so that we can take that
into our inspection or our observational frameworks, and test as it were provision and healthcare provision against that ambition. But this process of developing the strategy and applying that process is also about CQC, developing and strengthening its own skills level and understanding level, both in
practice terms for social care and in clinical terms for health. We can only do that actually by bringing in expertise, so the very nature of the approach really is to work with national organisations. You have got the expertise and to bring it to ourselves
and then uniquely apply that to our regulatory role. So, I think it is a really important point that Christine makes, that the co-production approach has got to be at the heart of how we operate it and. Just, it is really important, just to state
the obvious, it is an incredibly important issue both for older people and for some younger older people, as it were, and it is now, after the pandemic has receded, it has returned to be the principal cause of death in England and Wales. That is
not a death sentence, there is plenty of work that can be done with people with dementia, plenty of prevention work, so it is a really
Mr Ian Dilks - 0:27:48
worthwhile move for CQC to get into this improvement agenda. Given the increasing prevalence of the issue, it seems entirely
logical and to be commended, thank you. Mark, you have a question. It
Mark Chakravarty - 0:28:00
is actually two on the broad range of topics we have covered, the first one still on dementia. Again, very, very welcome. The question is - the central question of the way it
is worded - I just wanted confirmation that it will include diagnosis of dementia, not just people who have already got the diagnosis, because that seems to be a very critical part to make sure there is good care. And, if I can be cheeky, I
will ask the other question which was on the emergency care. Very, very helpful mapping of the PR5 to the SAF. It just struck me that one very important line – Outcomes - was blank and I just want to understand whether that is a “it
didn’t map”? Is there something that we are missing there, is there a
Mr Ian Dilks - 0:28:44
gap there, or is that what we would be expecting? OK. Well, James, and then I don’t know, either Prem or Chris, but I should thank you. That’s my second question being asked,
Mr James Bullion - 0:28:52
so we are doing well. James. Well, just to confirm yes, the early diagnosis and the variable experience of that process across England.
Mr Ian Dilks - 0:29:01
Prem Premachandran - 0:29:05
Yes, absolutely at the core of the scope. Thanks James. Chris. Just to
Chris Day - 0:29:10
do, I think, two points on that. Primary care is involved
in a co-production as well. So just to say, just to sort of link those two points back together, it starts with, they are not just involved in the inner production stages, they are involved right from the get-go. I think it is…, in terms of
the outcomes, a lot of this is about outcomes that appear elsewhere in urgent and emergency care. So, we are looking at pathways as well, and it is probably not very clear in the document you have got there. So, what we could probably do when
we come back with the final report, we will show the link between the information we have gathered and the wider outcomes. Because part of the issue here is the work we are doing is around outcomes that happen before people arrive into urgent and emergency
care or after they have left urgent and emergency care. They are not about the physicality of being in that environment, so we will try to cover that off when we present the final report back, if that makes
Mr Ian Dilks - 0:30:03
sense.
Prem Premachandran - 0:30:07
I think I agree with Chris. I think it is a good question actually, but what we are doing is rather than fixing the outcome,
all the other things will capture those outcomes in this one as well, rather than looking at the outcome separately. So, it will be one of the other three thing will capture those outcomes, part of it. Did
Mr Ian Dilks - 0:30:27
that answer your question Mark? I think so,
Mark Chakravarty - 0:30:31
but I liked the fact that we will get more detail when it comes back, to sort of see how it impacts. I mean, I think we have got to always remind ourselves that, you know, outcome sounds very close to impact and that is what
we are trying to drive. So, making sure that in the approach when we will be doing the assessments that we actually keep that always in mind. I understand that it might lie outside of the specific service that we are evaluating, so very helpful from
Mr Ian Dilks - 0:30:56
that point of view to get more detail. Stephen. I wanted to raise one
Mr Stephen Marston - 0:31:00
about the Thirlwall Inquiry if we are OK to move on to that? It is really just sort of, how do we, as an organisation, take the learning from that whole incident,
disastrous and tragic as it was? And there it is clear, you know, that we are responding to the Thirlwall Inquiry and that will hopefully get a full, deep understanding of what exactly happened there, what went wrong, how could it have been avoided? And there
may be some different form of learning that we need in addition to that, which is more about, given developments over the years since the Letby case, do we feel we can now be fully confident that if people had that sort of concern, those working
in a care setting or service users, if they have serious concerns, would they now be confident with everything that we have tried to put in place in raising those concerns, would they know how to raise those concerns and would people listen? So it was
kind of updating that whole horrible set of circumstances to the present day, so with everything now in place, Freedom to Speak Up Guardians, the emphasis we put on well-led within the Single Assessment Framework, the welcome we now have to help people raise concerns and
worries, could that still happen? I think that would be useful
Mr Ian Dilks - 0:32:38
learning for us. Thanks Stephen. I think that is a really, it is a
Mr Ian Trenholm - 0:32:43
really, really important question. I think there is a number of strands to what you’ve just described. I think in terms
of Freedom to Speak Up as a as a starting point, I think I the notion of Speak Up is now much more embedded than it was - bear in mind, you know, this related to events nearly nine years ago. So, I think people have
now seen Freedom to Speak Up work well. Many organisations have got Freedom to Speak Up Guardians. We obviously host the Guardian service, in fact I see later on the agenda, we will be hearing from the guardians directly. So in that sense, I think the
architecture is there, the framework is there. I still think, though, as part of our work, we are still hearing examples where individuals are not necessarily feeling that they can speak up. I think there is, probably, people know how to, but whether they choose to
for a range of other reasons around fearing detriment and so forth, is I think, is still an open question. I think the spreading out of Speak Up as a concept into things like the professional regulators, the professional expectation that one will speak up as
a doctor or a nurse in particular, I think is far more embedded than it once was. So, I think people know more. If I look on a practical level and within CQC, we see something in the order of about 50% year-on-year increase in Give
Feedback on Care from members of staff and, and indeed from the public as well, because that is a subset of this, I think, potentially. So, I think we are better known as an organisation, people understand Give Feedback on Care, they understand concepts like Speak
Up, but there is this…, I think the continuing question around is the culture in the place the right thing? And it is something which, within our Single Assessment Framework we are explicitly looking at, so again, it is something which we continue to test. I
don’t think, hand on heart, I could say I am absolutely certain that people wouldn’t…, that there would never be a situation where someone wouldn’t speak up. I think in terms of the specifics around maternity, we have just done the maternity work that I was
referencing a few minutes ago, and I think again that will give us a sense of culture within maternity services and whether maternity services, as a service type, is different to other services. I suspect it may be in some respects, but may not be in
other respects, but I think the other component to this is probably making sure that we are learning the lessons directly from the Thirlwall Inquiry. Because, you know, one of the things that was quite striking about the Lucy Letby case was how long it took
the police to investigate the matter, how long the trial took, how long the jury were out for. That would suggest that the case was incredibly complex and I suspect the inquiry is going to struggle to come up with really short pieces of learning, but
I do think as we follow the trial, and being a core participant will be really helpful because it will enable us to learn as we go during the during the inquiry. So, I think a number of things. I do not think I can say
a definite yes to your question, but it’s exactly the right question.
Mr Ian Dilks - 0:35:55
It is encouraging that things that the organisation has naturally tried to do better in developing appears to be responding in the right way, but, as you say, let’s see what the committee says.
Elin Sams - 0:36:08
Would it be alright to come in just quickly on the dementia strategy? One for James really, around what the dementia strategy means for CQC staff who are carers, and whether we are considering co-production with carers at CQC and also just in terms of staff,
Mr Ian Dilks - 0:36:30
existing colleagues who developed dementia as well? Thank you, Yes,
Mr James Bullion - 0:36:33
thanks for the question Elin. It points to a good point CQC as an employer, but actually all employers, large employers of carers. So, as the question in the paper says, part of our approach in
the strategy is to consider the lived experience of people with dementia, but also their family carers, and so a great deal of our focus will be what should “good” look like for those people? And some of the research that we are undertaking as well
to formally record where best practice and innovation is, as part of doing that, for us as an employer we will learn what good practice looks like and can bring some of that into the organisation. But, of course, it would make sense too, given that
we are a large organisation with many family carers inside us, to use that resource for our own internal research, so we will be reaching
Mr Ian Dilks - 0:37:28
Mr David Croisdale-Appleby - 0:38:31
out to the carers network to do that. David. It is not just older people, but we have an increasing number
of people with early-onset dementia, and that is from really aged 30 onwards which is not generally known by people. These are individuals that also require a great deal of care. You might like to know that we do not refer people from Dementia UK, from
our nurses, to many organisations, but the principal one that we certainly do refer to are the Samaritans because so many carers of those with dementia are on the suicide risk list. So, that offer is there James, I hope it’s helpful to you in terms
Mr Ian Dilks - 0:39:20
of co-production, etc. thank you. Thank you David. Let’s just capture that as an actual take-off line. Christine, we should probably make this the last question because we have other people joining us. Chris, sorry, if there was something, I will come to you, but Christine
first. Thank you. I just wanted to go back to the Thirlwall Inquiry,
Ms. Christine Asbury - 0:39:35
and just sort of really to get some reassurance. As an agency that had a role in relation to the Countess of Chester at the time of the Lucy Letby crime, that we
have taken this as an opportunity to learn as we have gone along, not rather than waiting for what will obviously be a complex Thirlwall Inquiry, and probably relatively slow as a result of that, that we have used this as a learning opportunity and that
Mr Ian Dilks - 0:40:09
the analysis of that come back to the Board.
Mr Ian Trenholm - 0:40:11
We can certainly do that. We absolutely have already done that, but we
Mr Ian Dilks - 0:40:16
can certainly do that at some point in the future. Chris, did you want
Chris Day - 0:40:20
to say something? Just it was on the point of how we encourage colleagues in organisation
– Ian answered it in part by saying we have seen a big rise in people using Give Feedback on Care in care settings to give us feedback, so direct frontline staff. We have also used different techniques over the past year, year and a half
in particular, where we have brought people out of their normal environment to hear their story. So, often we have some initial concerns that we are not hearing everything we need to hear, but again we do a well-led review. So, we have got used to
the idea of physically relocating the conversation to a different place so that people feel more able to give their views. We have also brought people together as a group, so we actually brought together 200 midwives to talk about – anonymously - to talk about
their experience of care across the country. I think both of those techniques are things that we wouldn’t have done four or five years ago, but they are very good at eliciting information that helps us then triangulate what is actually happening in an organisation. In
both instances, one has helped with the with the overarching report for maternity, the other one has helped us with two well-led reviews for what would have previously been seen as very good organisations, but it helps us to get to the root cause. So, like
Ian said, I don’t think we can say there is a perfect answer here, but I think there is some different techniques that we are trying to help
Mr Ian Dilks - 0:41:48
people feel confident about reaching out. Thanks Chris. I think we should probably move on. I actually had
four questions and three were asked by my colleagues. Could I just make one future request? I mean it is implied in some of the comments, but I mean we obviously are participating in two significant inquiries, neither of which were foreseen, but we don’t carry
lots of staff to do this. I know it is costing us money that we are not being funded for, and there is also an issue that we are potentially going to have to run, at a cost and some risk, systems that we were going
to decommission and ought to hold the data. I think it would be helpful in the future, Board, if we just have some sighting of what it is costing the organisation, what we are doing about it and the risks we are running as a consequence.
I mean there is no choice, but I think it would be helpful to have that visibility, but that is for the future. Thank you very much indeed colleagues. I did say I would let that run on, it’s rather more than I thought, but there
was so much in there it would have been completely wrong to stop it after 20 minutes. Kate and Chris over to you. I think we have a Corporate Performance Report. I think, Kate, you might want to introduce it. Usual rules, we have read it,
but any points you want to highlight and then we will go to questions.
Chris Usher - 0:42:57
Thank you. Thank you. Good afternoon, all. So this is our Corporate Performance Report for Quarter 3. I am going to shortly hand over to Chris who will talk a bit about
a couple of performance highlights and talk about the internal audit actions. But first, I just wanted to talk a bit about risk. So you might have noticed in this paper that the risk section is larger than it usually is, and that reflects the work
we have been doing as an organisation to really challenge ourselves about whether we are judging our risks accurately, and particularly on the kind of question of likelihood. So, we have had discussions as a SRT 30 group, so our senior leadership team, we have had
discussions as an Exec Team, we have also benefited from a new Risk
Ms. Kate Terroni - 0:43:34
Manager, who has come and joined our organisation as well. So, I just want to talk to a couple of risks that you would have noticed, have moved, and then I want to
talk to the three risks that are still exceeding tolerance, if I may? So, very briefly, Risk S2 around effective governance in place. The likelihood of that has reduced as a result of the work we have done around establishing sub-committees of the Exec Team and
really implementing our commitment around one-touch, decision-making, so that has had some successes. People and Culture Committee, about two weeks ago, also agreed to an increase in resources within the Governance Team. So this is a very lean team that would really benefit from having more
colleagues doing the job as well. So, we see that risk coming down further in response to getting some more colleagues in the team working on that as well. S3 around delivering transformation effectively. Again, that likelihood has reduced because we are now, as of yesterday,
live across the country with our new Assessment Framework, so we will now be, as of yesterday, working with all providers through our Single Assessment Framework on our new regulatory platform. It has been a long journey to get to this point and there is still
lots more work to do, of us and supporting our providers to work with us differently, but a huge success to have got here and that risks reflects the fact that we are delivering transformation as we originally hoped to. I just want to move on
down to P1, the risk around retaining…, recruiting…, attracting and retaining our workforce. So, this risk is reduced because, actually, we considered the fact that in the last calendar year, in 2023 we had 30,000 applicants who wanted to come and work with us as an
organisation and these are high-calibre applicants. So, actually that question about are we struggling to recruit, certainly isn’t the case across the board. There are still specific challenges around legal, technology, data and insight that we are putting plans in place for, but we felt on
balance we are certainly recruiting a good calibre of colleagues across those other areas, as well as noting those challenges in those couple of groups. And then probably the final thing I want to say, just before going to the exceeding risk, is O1, our operational
workforce is not as productive as it needs to be. Our new Single Assessment Framework is giving us a kind of level of granularity about what our colleagues are doing and where we are with our assessments, of providers in a way that we have never
had it before. So, now, any member of the organisation, any member of the Exec Team, operational managers now have access to a dashboard that shows them where everyone is in the assessment process, which quality statements they are assessing against and how far we are
away from sharing those results with the public as well. So, there is just a few highlights about some risks that have moved on and are now no longer exceeding tolerance. And then I just want to talk to the three that are on Page 18
of your pack which are the three that are exceeding tolerance. The first one is P1 which is around our colleagues being insufficiently engaged in our cultural change. This is a risk that has reduced down since we have had a conversation as a Board about
our cultural change plan. So we have got a plan and over the next couple of months, particularly in April and May, we are engaging the whole organisation around our values and our associated behaviours. So, this is a risk that is currently still exceeding tolerance,

2.0 Strategic Discussions

but we anticipate in the next three or four months or so that reducing down and coming into tolerance. O2, that we don’t make an accurate and timely assessment of the quality of care and risk for people. This is a very time-specific risk and, as
I say as, of yesterday, instead of, maybe for about two months, we have been working on the two systems depending on where you are in the country, as we rolled on the Single Assessment Framework across the networks. Now, everywhere in the country is live
with our new Single Assessment Framework and our ability to have accurate information that we can share with the public in a timely way will increase day on day as that new way of working rolls out. So, again, a risk that currently exceeds tolerance, but
will be coming back into tolerance, we expect, by the end of the financial year. Then finally, our last one, O5, around Siebel CRM Recovery. This is our legacy system that we are in the process of decommissioning and we anticipate having concluded that by the
end of this financial year as well. So just aware that we have had some discussions, particularly in our Audit and Risk Committee, about a sense that some of these risks aren’t moving and where they have been exceeding tolerance, we have not had a plan
to get them back into place. I am hoping the work that has been done over the last month or so shows that some of those are now back into a place we feel comfortable with, and where they are exceeding tolerance, we have got a
plan now to get them back in into place. So that is what I just wanted to say on risk. I am just going to hand over now for Chris to talk about Performance and Internal Audit. Thanks Kate, So just a few bits to pull
Chris Usher - 0:48:35
out on performance for the end of Quarter 3. First thing to note is we have revised the pack based on previous feedback, so hopefully that is well-received by Board, grateful for any feedback after the meeting or during, for that matter, on the presentation of
that. So, just three areas I was going to pull out. So, similar to last quarter, kind of three probably hot topics. Safeguarding alerts and whistleblowing. We are seeing improved trends in this area, but our previous dip as a new contact centre as service went
live, means we are not achieving our KPIs. We are aiming to close the gap in performance through process review, training communication and we are now hitting our target in safeguarding concerns, but there is more to do, for example, safeguarding alerts, as you can see
in the graph on the right. It is worth noting that we are taking action, but this is just pulling out that it is not timely in cases. NCSC response times. We track four types of call in our call centre. Let me say, we are
just short of target in all, except for general enquiries. We have seen a slight decline from our previous quarter in registration, safeguarding and mental health lines, although in December we did hit the targets for safeguarding. Challenges faced are largely due to transitional period, again
with our new-look regulatory platform, but also resourcing challenges in the centre. And the last area to pull out would be registration. Currently 46% of applications are over 10 weeks old. This is an increase on the last financial year and the previous quarter. Volume of
applications continues to increase. We have resourcing challenges, both of which have impacted on our backlog and our ability to bring it down. Several initiatives have been put in place as well as a booster resource in that service. So, happy to take questions on any
of those or any other parts. Just a couple of bits to close on. So, in terms of our finances, at the end of September we have got an 8.5 million surplus on revenue expenditure. That is a slightly clouded position due to our budget profile.
If you roll that forward to the end of the year forecast, we are looking at a 5.8 million deficit which is probably more reflective of our forecast…, of our finances this year. That deficit is due to non-recurring pressures such as the closing stages of
our transformation journey and unfunded work that is impacting our grant-in-aid funding, such as the COVID-19 Inquiry. We are actively managing both of those to mitigate the overspend. On our capital, we are 1.2 million overspent for the year to date. From here to December that
will come down to, we are focusing a 0.4 million underspend by the end of the year and that is following discussions with the Department of Health and Social Care on remedial funding for our capital position. Then just one bit of… final close on in
terms of our internal audit, one thing that might stand out is that we have a number of overdue actions in internal audit. So, we have got 302 internal audit actions that we are tracking, just close to 60% of those are closed. At the time
of writing, we had 60 that were overdue. We have been hunting these down one by one, you will be pleased to know. We have closed 22 since the time of writing, 23 are just finalising their evidence and awaiting verification, 5 of asked for an
extension with legitimate reasons which leaves 10 that we are chasing down. So hopefully, we will close them all out in due course. That is
Mr Ian Dilks - 0:52:13
it for me. OK. Thanks Chris. Belinda. Put your mike on Belinda. I wonder if you could just elaborate more on the
Mrs Belinda Black - 0:52:21
decline in whistleblowing performance and what you think the reasons
Mr Ian Dilks - 0:52:32
are behind that. Or, anybody… Thanks Belinda, I think the dip earlier on in the year was to do with our changing onto a new system. I think we saw a blip in performance at that
point. That is starting to increase, and I think we are now getting closer to the measure that we are striving for. I think, , as Chris said, there is an issue of timeliness here, about the top priority ones, but they are…, action is taken
against all of them. I think we have got evidence that 99% of them have had action taken against them, and those who haven’t are still brand new. So, it is not as if they are being left to languish, but as Chris said, we continue
to engage with our teams on what more we can do about that. But we are taking action, we are just not always doing it within the one day. Do you think it is people then not recording things properly in the system, rather than action
Mr Tyson Hepple - 0:53:19
not being taken? There could be an element of that, yes, and I think that is part of the investigation that we are doing, is to have a look at whether it is not being recorded correctly. I would be fairly confident that our teams are
taking action because it is one of their top priorities, but there may be occasions where they are not being recorded, but I think the latest
Mr Ian Dilks - 0:53:42
uplift in performance is encouraging. Thanks Tyson. Any other questions for Kate, or Chris? Stephen. Thanks Ian. Thank you Chris,
Mr Stephen Marston - 0:53:50
thank you Kate for a really helpful report. Just wanted to pull out kind of a couple of linked aspects. One is, I think it is right to note on the organisational transformation. Just big congratulations, and then you have achieved go-live right across the piece.
I mean that is a huge, huge achievement. Colleagues right across the organisation have contributed to that, it has created a huge amount of work. Great. You know that is a really, really important aspect of performance. It does then have knock-on consequences through to the
risk that you were describing, Kate, around colleague engagement, because we now go into the phase of full embedding, socialisation, everybody owning it, feeling they understand it, feeling they can use it. So, you know, you very helpfully described the risk analysis on that, and it
links very closely to the work, as you said, being done on culture. The one that is not here so much is there is also an equivalent need, isn’t there, to sort of secure positive embedding of the whole system with providers? And it did make me wonder whether, kind
of perhaps, we needed a little more visibility about how the whole transformation programme, now it is in place and rolled out, sits with and works with providers. Perhaps, could we, should we have a bit more visibility of that bit? Thanks. Thank you so much
Mr Ian Dilks - 0:55:27
Stephen, and thank you for recognising the huge amount of effort that
Chris Usher - 0:55:31
has gone into where we are today with go-live across the whole
Ms. Kate Terroni - 0:55:37
country. I think I would not be doing it justice if I did not note the fact that this has been incredibly
difficult for people, and is still very fresh. If we think half of the country went live with this yesterday, and even though because we have rolled out network by network, we have had the opportunity to address issues as they have arisen, and those issues
have been in kind of three groupings really. One has been technology issues where we have been able to put fixes in place when we become aware of them. Some of them have been policy issues as we have got to grips with implementing our vision
around Single Assessment Framework. And some of it has been about ways of working. So, each time a new network has gone live, there have been less issues, but this is still a significantly different way for our people to work. I think for a large
number of people, despite the training and the fabulous support we have from our super users and many other colleagues, this is still a really tough time at the moment. So thank you for saying congratulations, I echo it, but we are still very much in
the thick of it, internally. I wold just say - I don’t know whether Tyson or Mark might want to come in on that - but also your point about how we regularly see how this is landing for our providers, I will hand over to
Chris to comment on that side of things. So, it is a really important
Chris Usher - 0:56:51
point, Stephen, this is not just a change of working, ways of working
Chris Day - 0:56:53
for us. It is also changing the relationship with providers and, in fact, people who use services as well.
What I would say is probably three things. Firstly, we have been really grateful, not only to colleagues internally, but to the organisations that had been part of the early adopters programme. Because they have really helped us understand how the system that we have implemented
and the policy behind the system works in practice. They have been instrumental in helping us unlock some of the tweaks and the changes and the improvements that we want to make to the system in the short-term. It is fair to say that we have
held regular ongoing dialogue with providers, as we do all the time, but on this particular topic and we have held a number of sessions where we have been both providing information and receiving feedback from them on how this is working for them. And that
has influenced some of our guidance that we have then issued to providers and how we intend to deliver guidance going forward. I think the third element for this is what this will mean in terms of what people will view in terms of an assessment
on the website. We have been having dialogue both with providers and actually with people who use services, because obviously this is where it really matters, the outcome of this matters. So, we have ongoing dialogue with providers and people who use services about how we
intend to improve. I think we talked at a previous Board about what we want to do in the short-term and how we want to develop over the next few months so that it is a more real-time view of what we think about the quality
through our assessment and through other information. We have regular dialogue and I think colleagues, some colleagues, may have joined ESAG, which is our external advisory group this week, where we talked about transformation as one of the update topics. And finally, just end by saying,
one of the most important bits is that people can hear this and use it to influence what we do next. So, we produce weekly insight information from both colleagues internally and from the views of providers and other stakeholders, including people who use services, and
that feeds back into our decision-making process and into the prioritisation process that we spoke about at a previous meeting.
Mr Ian Dilks - 0:59:15
Thanks very much Chris. Tyson, you wanted to add… Thank you. I wanted
Mr Tyson Hepple - 0:59:20
to also thank Stephen for his comments, but also to reiterate what Kate
said, because of the fact that we have gone live in half of England only yesterday it is clearly a challenging time. So, thank you to my teams. As a senior team, we continue to step up our engagement so that we are hearing what people
are saying and also responding to their concerns, and then that will continue. While I have got the floor, I also wanted to make a point about registration, if I may? I talked a bit at the last Board about our plan to deal with the
demand in registration around recruiting people, continuing to look at our processes and maintaining and possibly driving up our high levels of productivity. But I wanted to remind anyone who might be viewing that we do have a priority system whereby if you can demonstrate that
you will add capacity to your local system, we can consider…, we will consider your application within 10 working days. That is a system that is used, it is well-guided on our website, but I think it is worth reminding that in areas where capacity is
desperately needed, we can we can flex our system to make that work.
Mr Ian Dilks - 1:00:28
Thanks Tyson. So, we have two Marks, let’s make these the last two questions. Mark Chamber’s question and then Marks Sutton next. Well, I was just going to answer that question, if that is OK. Then, Mark can ask.
Mr Mark Sutton - 1:00:41
Mr Ian Dilks - 1:00:42
Mr Mark Sutton - 1:00:45
So, just to reiterate what Tyson was saying there, just
a huge thanks to colleagues across the organisation, not just in technology and data, insight and transformation, colleagues that worked incredibly hard to make this change happen but colleagues, inspectorate, assessment and regulatory colleagues that have worked incredibly hard to and continue to work incredibly hard
to adopt to this. Well it is a significant change, it is a new way of operating, it is a new regulatory model, it is new technology, it is new data and insight products, and we continue to engage with colleagues, we continue to take feedback
and make continual improvement. That will go on as for as long as is necessary, but excited for the new world that we were entering into
Mr Ian Dilks - 1:01:24
Mr Mark Chambers - 1:01:27
now. Well, other Mark. Thank you. Just back to the risk register, it is great to see this changing because, you know,
it is intended to be a dynamic, real-time tool for the team to assess the environment in which we are operating. So, I support the changes that have made. The thing I think you have just got to watch is that you don’t give credit for
work that we have not done yet. Having a plan is not the time to change things, it is execution on the plan, and we are in the very early days in terms of what needs to be done on governance and culture. Those are long-term
things. And I think even in relation to productivity, I am not sure we have…, we have got the measures now, better measures than we have ever had before, but I am not sure we have laid down what our best level of expectation is to
work out where we stand against that. On internal audit, I think every now and then, over time, you just end up with those difficult audit responses that prove to people leave, the world moves on, things have changed and a solution which looked plausible a
couple of years ago just is, either the problem has gone away or the solution won’t work. I think we have just got to have the courage, every now and then, to go through them as you as you are going, but to clear the deck
and then refresh the Management Action Plan picture. It may be one of
Mr Ian Dilks - 1:02:59
those moments. Thanks Mark. Mark Sutton, as a requirement to be on the Board these days you have to be called Mark. Mark Sutton, thank you for those observations. I was going to
make the same point that we rightly, I think, congratulate to those who have delivered this, but everyone in the organisation is having to go through a change. No human being likes change, we have recognised it, puts people under stress. So certainly, if any colleagues
listening to the call, just to say the Board recognise that and we will continue to do everything we can to ease through that process. Can I just ask one really detailed point - and I’d also (unintelligible) points on the risk register - we are
getting to the stage where it is a live document rather than static, so thank you for the progress being made. Just one really quick question on the registration, on the overdue. We have focused on this metric of over 10 days old, sorry 10 weeks
old, sorry, and we understand that there is more coming in, so we have got a number of staff, more comes in, inevitably it gets delayed. Can I just gather assurance on the tail-end that there isn’t stuff just getting too old? I mean if everything
is suddenly 10 and a half weeks instead of 10, that’s great, but with I want to make sure there is nothing that is 6 months or 12 months old, can you give me that assurance, or do we need to go away and look at
Mr Tyson Hepple - 1:04:15
it? I can’t give you the reassurance on 6 months old, because there may be a small number of complex cases in the system. What I can say is that we also monitor the average age of the work in the system, which, from my experience,
is the sign of a healthy case working system. The average age of all of the work in the system - the 10,000K applications - is 7.5 weeks, and the average age of all applications, the sort of 46% of applications that are over 10 weeks
old, the average age is 12.5 weeks. What we have been doing recently is that the older work in the system, we have been going through and putting that into our priority system. So, we are dealing with the older work first. We could get the
10 week figure down by focusing on the work that is nearer the 10 week mark. We are not doing that, we continue to do bring in the tail as it were, but I will come back to you on what the oldest cases in the
Mr Ian Dilks - 1:05:11
system are, but there will be few of them. Thanks. It is a detailed question, but sometimes it does happen, and you look at averages and you ignore the fact that something has gone off the scale. That is great, thank you very much. Thank you
for your observations on the report, Kate and Chris. We have a couple of external reporting updates now. The first is from the National Guardian’s Office and then Healthwatch, England. I’m going to suggest that we take a short 10 minute break after NGO before we
go into HWE, so we might let Louise know. So, we are going to be joined by Jayne Chidgey-Clark. Jayne is dialling in. We have a technology problem, I am told, that although people listening in can see this room and they will be able to
see Jayne, we cannot see Jayne. So, Jayne, if you are listening, we can’t actually see you. We have a tiny computer in the corner, so some of us can see you on that, but it won’t help us listen. So, let me hand over to
you. We have read the paper, thank you very much indeed, but if I could ask you to pick up any particular highlights you want us to recognise, and then we will go to questions. Thank you. Thank you very much Chair, and thank you for
the invite to join you as ever. It was May last year was the last time I came to present formally to Board, and it is always good to come and talk about the work of the National Guardian’s Office and to hear your questions, comments,
feedback. So, I will take it as read that you have read the report. I think the things I would really like to highlight, and listening to a little bit of your earlier conversation around the Thirlwall Inquiry, I will definitely pick up on that in
a moment. But let me just start by just reiterating, which I did in May, we published a report last year based on the Staff Survey and I remain concerned at the decreasing confidence that we have seen again in workforce in the NHS in their
confidence that they can raise matters of concern and that they will be responded to appropriately, and that remains a concern. Never more was it more important and, you know, when we see high-profile cases such as Thirlwall, that obviously just emphasises that. So, the work
that you are doing as a regulator, that we are doing in our office in terms of the support through improvements and Speak Up culture, the work of NHS England and other regulators stays as important as ever. So, what I would like to talk to
you about first is what we have been doing since the Lucy Letby verdict and you will see in the report on Page 3 that, as in various actions that we have taken, I was invited to speak with Secretary of State, we have raised various
important issues to him and to the Department of Health and Social Care around adding our voice to the voice that we need to, including increased investment in training and support for good leadership, implementation of the KAP Review, and absolutely ensuring that leaders put the
high priority on their culture and Speaking Up culture and responding to workers’ concerns to help reduce the likelihood of harm coming from workers not being listened to, with that important voice in terms of patient safety and worker safety that they bring. I also spoke
to him about compliance levers and I feel really concerned about the ongoing challenges of enforcement and assurance on a routine basis regarding Speak Up culture. Your work and obviously we have been very involved with CQC, looking at the well-led domain and we have really
welcomed you inviting us to look at that with you, but as ever with a regulatory system, you are not in every organisation all the time and I really welcome the new regulatory framework, the more data-led, and obviously we can feed in what we know
of that, but I am also very much asking NHS England, and will be saying the same when I go to their Board, that we look at the contractual compliance mechanisms as well in terms of Speak Up culture because that is really going to be
important. I also talked to the Secretary of State around strengthening the role of, and the training and the support for guardians who provide that additional safety route when other routes within organisations are not working. I am happy to take any questions around, thoughts around
Thirlwall, I heard some of your conversation earlier. What is really important is this January was the deadline for all NHS organisations to have done a review against the new NHS England Freedom to Speak Up policy and our joint guidance, the sort of planning and
support tool and Boards to be discussing that, and I know that will be part of your inspection of well-led. What I am really keen is to ensure that we have some way of seeing if organisations are doing that and taking it seriously. Obviously there
is not an option for some organisations to not do this in the in-depth, organisational development type way that we need to see to get real change. So, it is going to be really important to see how that mandate to do that review is actually
monitored and implemented in practice. I have also been talking with national bodies, particularly the NMC, GMC and Health Professionals Council, looking at what more we can do to strengthen guidance and support for professionals when it comes to escalating matters and understanding their responsibilities to
speak up, and as managers, to listen up and act up, and that is really important. We have been undertaking some work with NHS England - and you have been round that table as CQC - in terms of escalation routes which the Minister has asked
us to look at as a set of patient safety leaders to help reduce the risk of this happening again and that work is really key going forward. We are not trying to reinvent wheels and invent another regulator, but we are absolutely looking to see
what more needs to be done to ensure those escalation routes are known by everybody, but really importantly, that they are then acted upon through the parts. My report covers our Speak Up Reviews and our work with partners. I don’t intend to talk about that
now unless you have got any questions for me. I did want to just highlight the ongoing important work of looking at primary medical services and the integrated care systems because they are less well-developed than trusts in terms of work in the Speak Up culture,
and they have the particular challenges in primary medical services, so that work is really important going forward. I think probably what I would like to do is remind you that we laid our annual report and you will have seen copies of that. Happy to
take again any questions on that. That went to Parliament in November last year and I also want to thank the Audit Committee of CQC. We had a very robust and useful discussion last year with Audit Committee around our risks and particularly around metrics of
measurement and impact. As a result of the discussions with you and looking internally ourselves, we are currently working with some researchers, which is represented here, to look at what pre-work can be done to get a successful search bid to look at implementation of the
Guardian model. It is time now to look at what models work well, what more needs to be done, so we have a more robust evidence base and that work is really important going forward, but we need the funding to do that. Such research is,
you know, has financial implications, so we are working to do that with our stakeholders. I am very happy to take any questions, comments or feedback on the report and our work since I last saw you. Thank you. Thank you very much Jayne. Questions or
Mr Stephen Marston - 1:12:59
comments from colleagues? Stephen. Thank you. I have the role of working with Jayne and the Board of NGO which is really helpful, and I just wanted to say thank you to Jayne and the NGO organisation for all of the work they have done. And
particularly to draw out the importance of this for the discussion that we were having about people’s confidence in speaking up, but as Jane has rightly identified, there is some evidence in the wider NHS Staff Survey that actually quite a lot of people don’t yet
have confidence in speaking up. So, there is clearly more to do in that territory. The other point I just wanted to draw out was, Jayne mentioned the thematic review that NGO did recently on ambulance trusts. I think that was an important piece of work
because it doesn’t just sort of look at how do you put a Freedom to Speak Up Guardian in individual providers and health settings, but it looks across the piece at a group of providers - ambulance trusts - and did find some significant issues about
culture and Speaking Up. Everything then depends on follow-through and the action that people take, which I think is why Jayne is rightly putting the focus on, it is one thing to do these reviews, it is one thing to come up with recommendations about how
we could develop a stronger Speak Up culture, it is a very different matter whether these things are then acted on and how they are followed up. So, we need to put the focus with NGO and in the ALB on that question, of ensuring robust,
timely follow up of the recommendations and findings that NGO have. Thank you. May I come back on that point please, Chair? Go ahead.
Mr Ian Dilks - 1:14:57
Thank you ever so much Stephen, and thank you for your support on the Accountability and Liaison Board and your check and challenge is
always well received. What I would say in response to that is that we convene a steering group to look at implementation of recommendations following that review, DHSC yourself CQC, NHS England and the Association of Ambulance Chief Execs sit on that, and it is really
important to keep the focus on this. But in the wider context of review recommendations, we know over the years there has been review after review, with more and more recommendations that organisations are asked to look at and there is varying levels of scrutiny of
the successive implementation of those. Such that, as a group of patient safety leaders, Rosie Bennyworth, Chief Exec of HSIB, is leading a piece of work across many of those patient safety groups and regulators to look at recommendations and what is in the art of
the possible to be much smarter about implementation of recommendations, databases of who is doing what and that whole assurance piece. So, that is ongoing work that we are really keen to be part of because the last thing we want to do is to use
resource to create recommendations that then sit on a shelf, and obviously there is a key role for yourselves in terms of inspections for relevant recommendations, implementation to see the evidence of that, et cetera, but really important piece of work. Thank you, Stephen. Thanks Jayne. Any other…? James. Just
Mr James Bullion - 1:16:32
echo the point that is being made about the importance of the integrated care systems work that we are doing and, of course, quality and safety and leadership are core features of the work there, and what we’re going to look at. The two pilots we
have undertaken, of course, are limited. I think, as we roll out the work subject to final agreement with government, as we roll this out, I am sure we’ll see themes emerging that relate to both patient safety issues and the Speak Up culture actually, and
it is a good opportunity for us to both reinforce the messages from the NGO, but also to gather evidence actually for whether the convening power of that leadership in an ICS is having an impact on the trusts and other NHS organisations that are in
Mr Ian Dilks - 1:17:19
Mr Mark Chambers - 1:17:22
local areas. Thanks James. Mark. An incredibly helpful report, as always Jayne thank you very much. I think it is just worth making sure that we don’t get overly focused on just one dimension that is limiting confidence for people speaking up. Fear and futility are the two
main drivers and, you know, there is plenty that can be done to better evidence that there are outcomes arising from people speaking up, even from some of the worst cases that we have seen. That will help people ultimately understand that things do happen. The
Mr Ian Dilks - 1:18:12
fear one is hard, that’s for sure. Thanks Mark. Chair, may I come back to that one, Chair? Just a brief observation around that one. Thank you Mark. That is indeed incredibly important, and I think the futility is really key. You know, what’s the point, nothing
ever changes, so that feedback loop, seeing those best of organisations that do keep engaged with their workers and tell them what is happening and showcase. You know, you said, we did whether it is about patient safety, whether it is an improvement idea, whether it
is something else. I think the issue of fear, sometimes founded because of the detriment that we see some workers who speak up suffer for doing that, and it comes back to that point that I made at the beginning around accountability. We need to see
robust implementation of the KAP framework. We need to see as regulators those conversations being had when there is evidence that workers have suffered detriment for doing the right thing, making the place better, safer to work, etc. and that will remain a huge priority. Thank
you Jayne. If there is no other questions, I will just finish with a comment from me. You did reference in the report, Page 8 I think, about Board development sessions and the work you do for trust. Just for the record, for people listening, you
did a development session for this Board a few weeks ago. So firstly, thank you for that. I think we all found it very useful and if there is any provider representatives listening, I would commend you to contact Jayne and organise it, request it in
your organisation as well. I hope you are inundated with requests, Jayne, and you haven’t got the resources, and that’s a problem for you to sort out. But thank you very much indeed for joining us, Jayne, appreciate it. Thank you very much, colleagues. Bye-bye. Having
said that I would take a comfort break now, we checked with Louise. She has a train to catch, it would be unfair for her to miss the train, so (unintelligible) is joining us. We haven’t got that long to go, but we have still got
two quite important topics, so I suggest we still take the 10-minute comfort break after Louise, but Louise, thank you for joining us. What I thought I would do is asked David, who not that long ago you took over as Chair, just to give any
observations or reflections as an incoming Chair and a segue into Louise and then, Louise will turn to you. Just go straight from one to the other, usual rules, so we have read your papers, but anything you would like to highlight please, that would be
Mr David Croisdale-Appleby - 1:20:41
great. David. Thank you Ian and when I have finished my very brief introduction, I will go and sit beside Louise so I am in the same firing line as Louise might be. For the benefit of you, Charmion, because you are the only non-executive director
who hasn’t met Louise before. Just briefly, Healthwatch England is a central organisation and there are 152 independent local Healthwatches. They don’t report into Healthwatch England, they are independent entities and they were set up in the aftermath of the Mid-Staffs Inquiry and the first chair
was the writer of the Report on Mid-Staffs, Sir Robert Francis KC. We are updating everyone today really because, of course, Healthwatch England is constituted as a committee of the CQC hence we are reporting as a committee. What are we? We are a small independent
organisation of around 35 people and the Chief Executive, Louise Ansari, is going to present our work to you in a moment, but just let me remind all of us of our purpose, which is to seek and report on the experiences of the public, of
patients and of carers across all areas relating to healthcare. So, without more ado, I will introduce Louise to you and ask Louise to do
Mr Ian Dilks - 1:22:25
the presentation. Right, thank you. Thank you, David, and thank you
Presenter 2 - 1:22:29
Chair for the introduction. The first thing I would like
to say is to recognise the very hard work that David has put in since he became our Chair in June, I think it wasn’t it, David? David has travelled round the country and done a huge number of meetings with local Healthwatch and really got
under the skin of our movement and has been a great support, even just in the last seven or eight months, so thank you David for such an excellent start. So, I am not, as you say I am going to assume the paper has been
read, I am just going to very briefly pull out a few points and then I am open to questions. So, one of the things that I do want to say is to remind people that we do hear a lot of positive comments, particularly about
the quality of care in every setting. Unfortunately though, we have heard throughout the period since I last reported which, like Jane, was in May last year, about the difficulties many, many thousands of people are having accessing care, and also the further emergence of a
two-tier system where some people are paying for care and other people can’t afford to do that, and some people are paying to get care faster and many other people - round about two-thirds of people say they can’t afford that. So, both this access and
two-tier system issue exists primarily in primary care and I will talk about dentistry a little bit, but also an elective care, both of those areas still extremely problematic. We had significant input into the dental recovery plan, which many of you will have seen has
been released today and reported on, and we welcome that as a really good start. Then, in terms of access in other areas of primary care, we have done a great deal of work on the proposal around Pharmacy First and we are going to be
reporting on that over the next two weeks. We have already spoken to the Health and Social Care Committee in terms of whether or not primary, pardon me, Pharmacy First is going to work to take pressure off GPs. Whilst there is a good amount of
support from the public, there are some areas of concern, including access to pharmacy, including medicine supply for a range of conditions and including whether or not pharmacists are being trained quickly enough, or indeed if they have got the right spaces within their within their
pharmacy. So we are going to be releasing that and we are going to hopefully do another study in a year or so to see whether or not Pharmacy First really will work for people. As is being talked about on and off through this meeting,
patient safety following the Lucy Letby case has been a real priority area for us. We have also been working with the CQC regional teams to try and improve the relationship between local Healthwatch and regional CQC teams and find a better way of escalating when
local Healthwatch have got concerns about safety in a particular trust or other healthcare setting. Then in terms of internally for Healthwatch England which, as David said, is actually quite a small organisation, there is only 36 of us and we have grant-in-aid of around 3
million pounds. Please note the section of my report on E D & I, which flows through every element of our work and the Healthwatch England Staff Survey which showed very positive results, and we have also got a number of organisational development programmes underway, including
creating a new culture set for the entire Healthwatch network and committee and staff. So very happy to answer any questions on any
Mr Ian Dilks - 1:26:21
element of the report. OK, thank you very much, Louise. Colleagues, questions or comments? Belinda. Thank you. Just wanted to talk more about
Mrs Belinda Black - 1:26:33
the Dentistry Recovery Plan because I know that you have had a lot of
Presenter 2 - 1:26:40
input into that. Thank you, Belinda. Yes, I mean the work on dentistry started well before my time as Chief Exec of Healthwatch England, and I would say for at least the
last four years, Healthwatch, local Healthwatch and Healthwatch England have been taking the experience, the worsening experience of people, back into the system, obviously which is our job, and particularly to the Department of Health and to NHS England and more recently, since commissioning has been
devolved, into Integrated Care Boards. What people have increasingly said to us is, has been reported fairly widely, there is a lack of NHS provision. I mean there has been declining provision for decades of NHS dentistry, but certainly since the pandemic that plummeted that provision,
and it hasn’t got back up to pre-pandemic levels, nowhere near. That has created some areas of the country where you pretty much can’t get an NHS dentist. I have met people, these are not isolated incidents, who have pulled their own teeth out. It is
really heart-breaking actually. I have met people who can’t get NHS dentistry for their children. Then, we are also finding in terms of the cost of living pressures that people are avoiding dentistry because they can’t afford private dental care, and because of the cost of
NHS dentistry now, some people are even avoiding that if they can get an appointment. So, through a range of methods which you could possibly call campaigning to a certain extent, we have been exposing this around the country. We have been talking to the media
about it, we have given private briefings into the department, into NHS England, who have been very receptive to what we have been telling them and highlighting the experience of people. That has been going on - you have to be tenacious about this kind of
change – that has been going on for a long time, so we were really delighted actually that the Department and NHS England have together worked up this Recovery Plan which we think is genuinely a really good start to fix some of the issues, but
really deep and radical change is needed to fix the underlying issues around the dental contract in order to make long term change for people. But, as I say, we are really happy, particularly on children’s oral health, particularly on things like dental buses as a
short-term fix for some of those areas, and the network will continue to press on this issue until the swell of poor access dies down. Some
Presenter 1 - 1:29:20
of you may have seen Victoria Atkins as Secretary of State this morning on the breakfast programme really talking in
some detail about the new announcements. So, it is fairly hot off the
Mr Ian Dilks - 1:29:34
press too, Louise. Thank you. Any other…? James. Thanks very much. I
Mr James Bullion - 1:29:41
wondered, it was very interesting what you have said in the report around the support to the Healthwatch networks, and in
the context of the systems work we are doing with integrated care systems now at CQC, just your perspective really on how sustainable the networks are? How connected you feel their work is in the development of place and devolution of the permission of the NHS
to get on and change and improve at a local level? I sense from your description in the paper that there’s a mixed picture. Thank you,
Presenter 2 - 1:30:19
James, that would allow me to get on my soapbox for quite a long time. I will respect the time
of the Board. The resourcing and the ability for the 152 local Healthwatch to do their job is in an absolutely dire state for most of them. The funding in real terms has reduced by around 50% since the creation of Healthwatch, about 10 years ago.
They are responding really well to the creation of integrated care systems. Almost all Healthwatch are grouping together on the footprints of ICSs and a number of ICSs, actually around 60-70%, are giving sometimes small amounts of funding to local Healthwatch to work together across the
ICS patch. Many Healthwatch are now in the governance of ICSs, sometimes on the ICP, sometimes on committees of the ICB, and that’s all good on the surface. But underneath that, the ability of a local Healthwatch who, on average they have four members of staff,
their funding varies from about £60,000 pounds to around about half a million. The variation is absolutely huge, on average they get maybe 100- 120,000. Obviously they are commissioned by local authorities, that funding has shrunk over time, many of them do a really fantastic job,
but in terms of actually covering the population, being able to listen to everybody’s experience, particularly reaching out to communities who suffer the worst health inequalities, they are just not equipped to do that. So, I said all of this at the Health and Social Care
Committee this time last year, and that committee did ask the Department to look into the resourcing and the structure and the commissioning of local Healthwatch, which I think needs a significant amount of reform. We are, as a committee of CQC, the statutory body set
up to listen to patients and we are not resourced sufficiently to do that and we do make that case. David has been very clear with me that we need to continue to make that case and make sure that people understand the value of Healthwatch,
so that we’re not funded for the sake of it, but we can actually show the impact we have for people out there. When I make my visits to
Presenter 1 - 1:32:44
local Healthwatch – I am making one tonight that will go up to Peterborough and Cambridgeshire -
they are increasingly bringing in the Integrated Care Board Chair and Chief Executive to those meetings such is the importance that they attribute to both listening to and being seen to listen to the voice of the patient, the evidence and voice of the patient, which
Mr Ian Dilks - 1:33:16
is encouraging. The demand is there, the need is there. I didn’t see
Chris Day - 1:33:24
which hand went up first, was it Tyson or Chris? Chris. Just to say to Louise and her team thank you, because of the work that you are doing to help us with
our thinking around State of Care, particularly the focus around dentistry, but also in other areas like our work on systems, like our work in mental health, like our work on access more generally, including to primary care. All of the things that we report about
in State of Care and other places in part comes from the work of you and your team. I know you know that, but it is an opportunity just to
Mr Ian Dilks - 1:34:19
Mr Tyson Hepple - 1:34:22
Presenter 2 - 1:34:43
say thank you for that work and (inaudible) … delivery, and you know people being happy
to be at work. We do already have a set of values, I don’t think they were, kind of, driven from the ground-up, so the process that David and I have put into place is that we have held a series of workshops with committee, with
staff, with the local Healthwatch network. The local Healthwatch network are still in those workshops and through a really kind of wonderful set of discussions, each group in in our organisation is coming up with very similar values. So, I have asked for a set of
values to be created, around about five values which really encapsulate the work we do. Everybody at the moment is coming up with identical values, things like candour, things like equity, collaboration, and then, once we have decided on what those kind of 5 or 6
values are, we will go ahead and determine the behaviours that lie beneath that, and then how we will hold each other to account, all of the staff and all of the volunteers for delivering on those values. Then we will try, we will have a
piece of work to keep that alive and keep it meaningful, and testing it out and putting it in appraisals and so on, so that that is really embedded as part of who we are as an organisation. Because it is the behaviours that are the
Presenter 1 - 1:36:15
important thing. The values themselves, yes, they are important, but itis only through the behaviours that you see those values being evidenced. As Louise said, it is vital that culture work is not top-down, it involves everybody, and then everyone feels that they are committed to
it, they feel a sense of parentage for it and therefore they want to
Mr Ian Dilks - 1:36:43
live up to it. Thank you, David. Any last questions? I just had… James, it is probably more one for you unless Louise wants to add to it. I was just interested
in – we touched on this a little bit already - but just interested in your perception from the work we are doing with ICSs, ICBs, of what we expect the role of Healthwatch to be, both locally, and indeed its use to us. I think
Mr James Bullion - 1:37:12
we have made a presumption in the work that we have done, that Healthwatch is a facilitator of voice into the ICS, so we expect to see, as it were, that in action and actually, without commenting on the specifics of the pilots, the reports which
are not published yet, I can anticipate a theme emerging that that might not be the case actually. And I think it probably backs up what Louise is saying about the reality of sometimes how complex and large ICSs are and the difference between the ICB
and the ICP and those two relationships, but I suspect that we will find more to do, and some good practice guidance emerging as a result from that. Can I just add very briefly? I think there are some areas
Presenter 2 - 1:37:59
of the country where the Healthwatch
or the groups of Healthwatch really work very closely and are very kind of embedded in the work of the ICS. I think West Yorkshire is a good example, but there are others. Then, there are some areas of the country where actually listening to patient
experience through whatever means, Healthwatch or you know other means of engagement, hasn’t taken priority. So, I think it is more about variation than, you know, is it is it happening at all. Can I just
Mr Ian Dilks - 1:38:30
Presenter 1 - 1:38:33
Mr Ian Dilks - 1:38:33
make a final comment, Chair, that is really about the ICS,
Presenter 1 - 1:38:34
the ICB, your point that you just referred to? When we set up the ICS system, the Alzira system in this country, one of the things about that system developed in Spain was it was fundamentally about operating at neighbourhood level, secondly at place level, and
Mr David Croisdale-Appleby - 1:38:59
only thirdly, at system level. And one of the things that our Healthwatch local network allows us to do is to operate very much at neighbourhood, as well as place level. And that is something that the integrated care systems and the integrated care boards are
tending to operate quite significantly at system level, so I think we are a great facilitator in bringing about the right kind of focus for
Mr Ian Dilks - 1:39:27
the integrated care boards. OK, well, thank you very much. James, thank you for a beautifully crafted response to my question.
We look forward to seeing the variation, and perhaps getting an understanding of why it happens and the consequences. David, thank you for the introduction. Louise, thank you for coming, you may take your soapbox and I hope you manage to get your train. Thank you.

2.0 Strategic Discussions

Other colleagues, can I, as promised, try and take a 10 minute break? If we could try to be back for ten to with two important items to address, and then some internal governance, but 10 minutes. Thank you.
Mr Ian Dilks - 1:40:04
We now have a couple - thank
you for switching my mike on, Ian. I usually start with a recourse to everyone else to do it right, and I am always the first to get it wrong, thank you. We have two important things now, the first is the update on the LLRC.
So James, I think you are going to head this up, but Helen Rawlings, one of our colleagues, thank you for joining us. You might, when we get to you, just introduce yourself to everyone else given the fact we have some new colleagues. James can
I hand this over to you? Yes, thank you. Thank you Ian. Yes, so we are
Mr James Bullion - 1:40:43
joined by Helen Rawlings from the Adult Social Care part of Regulatory Leadership, Helen has got an improvement and integrated role actually, so it is a natural leadership for this.
So this, as the Board will see from the paper, this is part of our ongoing reporting back to the Board about the Learning, Listening and Responding to Concerns work, the action plan of which came May last year, we had an update in September. This
is another update. The Board will remember that at our last meeting we were updating ourselves on the work of the Strategic Oversight and Prioritisation Committee, SOPIC, who have taken, as it were, this piece of work and the broader recommendations monitoring work into a slightly
more cohesive and simpler oversight. So, we are at a very crucial time with this piece of work, so it is important obviously for the Board to receive an update on progress between last September and now, and Helen will go into the detail of that.
But we are also in the run-up to a larger consideration at the Board of the more independent evaluation of the progress that we have made in this area, so we are underway with the preparation for that in the background to this and again, Helen
will be able to outline the nature of that work as well. But I will
Presenter 2 - 1:42:25
hand over to Helen for the detail, thank you. Thank you, Ian. So, I am
Mr Ian Dilks - 1:42:34
Helen Rawlings. I am a Deputy Director of CQC and I cover as James said, a
Presenter 2 - 1:42:35
portfolio of integrated care, inequalities and improvement. As of January this year, I am pleased to have taken on a supporting leadership role for the important recommendations that we all know about and the associated work as a result of the Listening, Learning and Responding to
Concerns Review. Today, I will give an update to Board regarding the progress and present a forward view of the work and the outputs for the Review in the coming months. So we are now around 10 months from the initial Review process presented to Board
in March last year and resultingly, we know that recommendations were accepted and the action plan against these recommendations presented in May of last year. So in September, as James said, we presented a progress update and today I am pleased to update that further progress
has been made against the recommendations from the Review out, as outlined in the paper. The work continued since September has been led by our senior owners and really important contributions across the whole of CQC, many others from the organisation contributing to the work. I
think it should be really acknowledged that the focus on this work has been held with the utmost importance and our staff across the CQC are really committed to meeting the recommendations and really sharing that strong culture of improvement that we know can come from
this. So, you will also see from the performance chart in the paper that there is still really important work to do, and therefore we really mustn’t lose our focus on this and we should ensure that our staff, the public and our providers really see
and really importantly feel the change as the result of the Review. So, in the paper I have highlighted some of the work completed since October and I would also like to highlight some additional examples really that have come to fruition in the last few
weeks. So, we have appointed two new Freedom to Speak Up Guardians, development sessions for the Executive Team and the Board around Freedom to Speak Up have also been delivered and the Board completed the first part of their independently-led training and development on race and
inclusion, with further work being undertaken on this in the coming months. Our inclusive mentoring scheme was launched for 2024 and a really important further update to our standard operating procedure on how we manage our information of concern. This is a really important and thorough
work which has taken place to make sure that all of our staff are really clear and confident to manage any information that comes into us, and that when we record this it is done really to the highest expected standard. Finally, we have updated our
approach to human rights and included learning for our staff around how we deliver that and how we are able to apply that to our work across CQC. So, you will also see from the paper that the Leadership, Governance and Assurance regarding progress against recommendations
has been strengthened. We have made sure that how we work together to achieve the aims of the review has additional leadership support from myself, and that also reporting and oversight and how we are doing is monitored clearly and consistently in the organisation. The aim
is to ensure that if we face any challenges or barriers to achieving the high expectations set out in the review that these can really be addressed quickly and effectively through that process. Finally, moving on to our commitment for ongoing evaluation. So, as recommended in
the Review, we have got ongoing evaluation work taking place. We now move, as James said, to a really important phase to coincide with the one year and then the 18-month period since we accepted the recommendations and initial evaluation is planned to report the middle
of this year, and then further towards the end of this year. We have committed to include independent aspects into that evaluation, so that includes using an independent research agency to conduct some of our qualitative research with staff and partners and also engage in our
independent review panel members. So, these individuals were really fundamental in the Review and will be fundamental going forward, to really check and challenge our progress and help identify where we can complete further work. We have included questions in our recent people survey to capture
feedback from our staff on progress so far, and we are really ensuring this evaluation work gets to the centre of what matters to our staff at CQC, to our stakeholders who worked with us, the public and health and care providers. We really must aspire
to embed this change and that this change forms the basis of our ongoing culture and values at CQC, where every interaction that we have, we know really, really matters. Thank you very much. OK, thank you. Questions? While people are putting their hands up, can
Mr Ian Dilks - 1:47:22
I just ask one, partly detail, quite significant? You have helpfully given us a snapshot of last September and a snapshot now, and the good thing is most areas are getting better. The glaring exception is Speaking Up, and maybe this is a function of the
maths, but according to this the progress to date, the areas of no progress to date, are even higher now than there were last September. It has gone up from whatever it was something to 71%, so we seem to be further behind, or we have
revaluated that we are not making progress or something. So I mean, not meant to be a cheap shot, there is a (unintelligible) point on there, but what is the problem in Freedom to Speak Up? Why are we making progress everywhere else, apart from that
one area? It is to do with the sequencing. Mark can give you chapter
Mr James Bullion - 1:48:19
Mr Ian Dilks - 1:48:19
and verse on it, but a lot of this is to do with sequencing events in
Mr James Bullion - 1:48:22
the right order, so that impacts on when we can do what we can do over
Mr Ian Dilks - 1:48:31
the 18-month period. Yes, absolutely right. There must have been something that went awry with the maths there, I think, because we
Mr Mark Sutton - 1:48:36
have made significant progress. Bringing on board through an organisation-wide recruitment process two new Guardians to be able to support the work is going
to enable us to really, really supercharge our activity that we are going to do now which will involve training, engagement, reporting.
Mr Ian Dilks - 1:48:59
So, that is going to enable us to carry on with and complete those activities that we haven’t made any progress on. And of
course, we had our Board session and our ET session which is another factor in moving us forward in the recommendations around Speak Up. So, I mean there is the Board Development session that Louise led that I referenced earlier, and you have just picked up
on, and there were some actions coming out of that which will come back to the Board as specific initiatives. So, I’m not asking for precision, but presumably that is quite a big chunk of this red area which we would expect to see close here.
Mark, the other Mark. Yes, I think it is a similar point. I had a
Mr Mark Chambers - 1:49:42
problem with this, understanding this reporting, whether we are on track for this, or not. You can’t actually tell from this, because if things had not started, it may be because
they were dependent on other things and, therefore, that’s fine. But, equally, it may be that they ought to have started and lots of other things are dependent on that. So, it would be helpful, it would be more helpful to me to see this as
stacks of what is on track and what is not on track rather than the actual timing. I think the overall timing we need to see separately as a timeline and where are the big deliverables dropping off over the course of the work, but it
may well be that a lot of red shouldn’t be red. I accept that, but it is hard to see what the underlying pattern of orderly progression against a plan is. I mean just on that point, I am happy to pick up that and do
Mr Ian Dilks - 1:50:40
Mr James Bullion - 1:50:43
a slightly more friendlier version of this. It is the difference between should you’ve done it by now versus have you done it at all? This is measuring have you done it at all, and sometimes that is because we haven’t, but sometimes it is because
it can’t have been done by now because certain other things haven’t been done. So, I will get with Helen a version of what should we achieve, what have we achieved and I think it would represent it in a better light. I think that that
would be really helpful because the things we want to focus on and try
Mr Mark Chambers - 1:51:12
and help around this table are the areas where we are struggling to get things going. We need to do it now there is a problem for whatever reason and those are
the barriers that we need to try and help you break through. Yes, I mean, just to add to that, and then there’s a few hands going up,
Mr Ian Dilks - 1:51:27
Without making this overly complicated, it would be helpful to have an understanding of whether, if things are
not done, how much of that is the natural sequencing you talked about versus not doing it. The barriers, what the barriers are, it is part of the transparency, but is there something more to do to help, to make sure that we progress this rather
more quickly. I saw Stephen’s hands go up, and then Ali, so I will take those two, and then if there is any others, we will go to those as well. Stephen. Helen, thank you, a really helpful report I wanted
Mr Stephen Marston - 1:51:57
to follow up kind of
where you finished, which is that this is giving us a really valuable and helpful snapshot of kind of progress towards tasks and actions following out the recommendations. But, ultimately, we need to move this into a culture which is a rather more sort of intangible
thing to pin down. Have you taken the right tasks and actions to get to the culture that you really want? Could you say a bit more about how this how this is linking in to the wider work on values and culture, because if that’s
our endgame, kind of we need to see that this is this is feeding directly into the wider work on culture? Yes, so the answer to that is yes, it absolutely needs to move into that cultural perspective. I
Presenter 2 - 1:52:50
think what is important at this point
in the Review is that we make sure we move the fragmentation, if you like, of the recommendations into more of a frame of reference of the overall aims of the Review, and then link that directly to the CQC cultural development work. I think this
is, you know, this is my reflection on why the next sort of 6 to 12 months are really, really important and we mustn’t lose our momentum on getting subjective feedback on how people feel, how people are able to deliver their work and the difference
that this has made to them, and any further challenges that come up. So, in summary, in answer to your question, yes, it will absolutely be linked to the cultural work and that movement, I think, to the aims of the Review overall is probably a
wise decision to make sure that that interfaces really well with that work. Kate, I think you’ll want to cover this one. Let me give Ali his
Mr Ian Dilks - 1:53:48
question because, just conceivably, you may want to respond to that as well. Ali. Thanks Ian. Just to add
to everyone’s comments, really pleased to see an update on the
Mr Ali Hasan - 1:53:55
progression that we have had on this work and that this remains an important priority. I am also very pleased to see that we are definitely going to be bringing back in our independent panel
of viewers to give us assurance that we have done what we said we will do. In the paper we are quite clear on a target end date of sometime before the end of the year when it will be presented back to Board. And notwithstanding
the fact that concluding this programme doesn’t mean the conclusion of the work that needs to be embedded, as Steven said, I would be interested to hear a bit more about any risks, challenges or threats that we might see, that might potentially result in that
timeline for this programme’s conclusion being pushed back. Thank you. So, Helen, if you want to try to respond to that, although perhaps
Mr Ian Dilks - 1:54:38
Kate can respond to any of them, if she wants to add. Yes, thank you. So I think, Ali this is the really
Presenter 2 - 1:54:43
important next step for us. So, I think many of our senior owners for these actions and people who have been delivering the work are really best placed to reflect on those. Many of them have sort of overcome and identified risks and challenges so far,
but of course, at this point in time, to embed that into the culture of how we work, there may well be further barriers that exist around that. As we all know, we have had a move on to our new regulatory platform as well, so
we have colleagues working with new systems and processes as well, so that interfaces directly with our work around the LLRC as well. So, for me it is really important over the next sort of four to six weeks really to get a very clear and
documented overview of those risks and barriers. That hopefully will enable both our colleagues, but also at Board and Executive level, to make those decisions around how we can overcome those as an
Mr Ian Dilks - 1:55:42
organisation. So just to go back to Mark’s point, and I suppose, with
Chris Usher - 1:55:45
fresh eyes coming in with James and Helen, I wonder, on reflection, our eagerness to accept all 84 recommendations back in last May and the real appetite in the organisation to get on and start delivering
Ms. Kate Terroni - 1:55:58
was fantastic, I wonder whether, with hindsight, 84 recommendations is
a heck of a lot to implement at the same time. And actually, possibly, what might have been more constructive would have been to have mapped out what are the priorities to get done in the first 6 months, what should we be doing between 6
and 12 months, and what should we do between 12 and 18 months and thereafter? So, I think the challenge, as you say with this, is it is hard to tell whether we are on track or not, because our original ambition was to do all
of it straight away. So, I think that is a bit of a lesson for us to take out going forward. It came from the right starting point, which was we were eager to get all of this done, but I think the suggestion James had,
which is now with James and Helen, looking at this with fresh eyes, what do we expect to deliver over the next kind of 3, 6, 9 months, I think that will help Board know whether we are on track or on that side. Thanks. Thanks
Mr Ian Dilks - 1:56:46
Kate. Any other questions? Elin. Thank you. Yes. Just to note, there
Elin Sams - 1:56:53
is a new ask on the internet today about senior leaders undertaking race and inclusion training as part of the LLRC which is really great to see. I guess just a call from me
to encourage leaders to consider that that training and take it seriously, obviously, and any other wider training or, you know, ways that you can develop yourselves to consider this more carefully really. Thank you. I was going to ask you if you have any observations,
Mr Ian Dilks - 1:57:18
so thanks for putting your proverbial hand up. Yes. Thanks Helen. So,
Chris Usher - 1:57:26
a number of us had a training session yesterday which was very impactful and I think we are all still processing the discussion in
Ms. Kate Terroni - 1:57:31
the training session. Just a quick kind of fresh reflection
from me on the session was I came into it noting that there is a number of activities that we are doing in this area. So, if we think about reverse mentoring, if we think about our inclusive leadership programme, if we think about independent panel
members, the list goes on. The challenge we had from our trainer is that you are doing all that activity, but actually, when you look at your last set of people results, colleagues from black and ethnic minority backgrounds were describing an environment that they would
like to see as different. So, it was a very impactful training session. It certainly got, I think, probably a number of us thinking about what more, what different do we need to do, because we are doing a lot of activity, but as the trainer
kind of challenged us back is that translating to, you know, a better experience for that group of colleagues? So, I think we will probably regroup as a team to think about what next, and this was always as Helen said, this was always going to
be the start of a series of training and workshops as we tackle the kind of really key issues that came out of LLRC which is around our kind of racial competence across all levels of the organisation. So, we have started on that journey, there’s
a lot more to do, but kind of where we stand at this moment, I think, is just a re-look and a kind of challenging ourselves about all these things we have got in place, are they the right things, what is missing, what do we
need to need to do differently? And then seeing that training now rolled out through the rest of the organisation in kind of months to come as well. Thank you. Thanks Kate. If there are no other comments
Mr Ian Dilks - 1:59:11
let’s pause that. Janes and Helen, thanks very much
for that. I think, you know, we are grateful for the kind of re-look and the (unintelligible), despite my question, clear progress in some, many ways. Kate, it is interesting, you said, we agreed to everything at once. It is funny, it is not quite November,
and I think there was always that acceptance that it would take a longer time, and some of this is slow-burn stuff. But I agree, we didn’t have a sort of map, so maybe it felt like we were trying to do everything in one go.
Having made quite a lot of progress in some ways, and also learning from other areas, it probably would be a time to, if I say draw breath. I don’t mean suddenly slow everything down, but I mean just have a sort of better roadmap as
to the time we are going to apply to some of this stuff. Maybe that could come back to the board in some way, but we will leave that with you. Helen, thank you very much indeed for joining us, appreciate it. One other important point,
we put this down under the heading of learning from the external environment, I think we will probably do more of this in future. We are pretty diligent at discussing, internally, things that we can learn from that affect us directly. but there is an awful
lot going on in the outside world which has nothing to do with us in the first instance, but where people draw parallels or there are things that we need to contribute to. So, I think there is a few more papers along these lines coming
along, but the first of this is Ofsted. Obviously, a huge amount of commentary. Now, we have a paper in here. Joyce, I think you put that together, so thank you very much indeed for that. It is quite a long paper, we have read it,
but if you want to pick up any key themes for us and then we will go straight to questions. Thank you. Thank you Ian. I will just summarise
Ms. Joyce Frederick - 2:01:06
the key points from the paper before I take any questions. You are right, this is about
learning from our external environment and areas that impact on how we regulate. Following the death of the head teacher, Ruth Perry, there have been three reports on Ofsted, and probably not the last three, there may be more because there is really quite a bit
of learning from the case. The coroner summarised to say that it was the Ofsted inspection that had contributed to her death. While these reports are not aimed at us, it is appropriate that we review the findings and take the opportunity to learn and reflect
on our role as a regulator in this space. We have talked about our role with people at the centre of what we do and the fact that our purpose is about ensuring safe, effective, high-quality, compassionate care. There is a delicate balance in the way
that we listen and respond to providers knowing that we are focuses on People First. It is fair to say that we particularly know that some of our providers, who are small and probably medium in size, take regulation in a very personal way because it
is about the service that they deliver. The paper identifies four areas that we feel in response. Some of the things we had been doing already before some of these reports, but there are four areas that that help us really upon the road in the
learning and improvements that we may want to make. The first is our strategy, which was published in May 2021, and in that we have talked about how regulation must understand the challenges that providers face and the context in which they deliver services. So, we
committed really to be a far more collaborative regulator, to update our ratings more frequently, to focus on improvement, use all our regulatory levers, not just inspection, so assessment, our convening power, the co-production that we do with others, and use our national voice to raise
awareness about health and social care services. We also introduced our new Single Assessment Framework which already moves towards some of those recommendations in that we don’t have ratings limiters. Ratings are legislative, so it is a decision made by government, but we are doing more
within our Single Assessment Framework to really get the narrative about people’s experiences of care and think about how we score, as well as rate organisations. There is an element of self-evaluation that providers themselves and trusts, local authorities and our integrated care system work, where
they evaluate themselves to contribute to our findings. We also changed the nature of our inspection activity, so it is moving to an approach where it is far more collaborative, where we are talking to the people who are in services in terms of what they
experience, but also talking to the staff and leaders and looking at the environment in which care is delivered rather than, and I suppose, traditionally, people may see us, certainly on the television, with a clipboard and a tick sheet and think about compliance, but definitely
our on-site activity will be far more collaborative in that space. In terms of relationships, we recognise that that is key to trust and trust in the regulator, and we are going to refocus how we have relationships with providers. Probably, the paper focuses on the
coroner’s report and the processes that we need to look at ourselves and it identifies both where we are dissimilar. and there are things that we can do differently, really, in terms of reporting and the way we allow for factual accuracy checks and the way
we deliver reports. But there is a lot that we can learn from and it is outlined in the paper how we want to introduce more training and support for providers, particularly around wellbeing and areas where there could be distress and people have real concerns
about what we do. The report also identifies where we might do our quality assurance differently and how we produce our reports and the timing of those reports and the fairness between when the report is done, but when it is actually published and trying to
be transparent about where the provider has improved during that time, so what can we say about those improvements? We will closely monitor the implementation of our Single Assessment Framework. It is a new framework, we want to get it right. We have heard from earlier
doctors about there is more we can do around the technology and about how they share information with us. We are looking to make sure that those improvements are made and our work is not burdensome. We want to evaluate our new Single Assessment Framework, so
there aren’t any unintended consequences and we evaluate to say, is it effective, is it having the impact that we want in terms of making sure we identify risks, almost certainly, but also look for improvements that providers have made? So, there is a lot that
we are doing in response. I will stress that my paper is not a delivery plan, so it is not, you know, we are doing these things, and there are timescales attached, but we have considered the points that we need to learn and the areas
that we want to improve. So, I will pause there and respond to any
Mr Ian Dilks - 2:06:11
questions. So, Stephen. I think Christine was first. Christine. Thank you, Yes, I mean I welcome this review from a people point of view and
Ms. Christine Asbury - 2:06:21
from a process point of view. I just think it is
important to note that Ruth Perry’s tragic death resonated very significantly, with particularly providers of social care who, as you say, take it very personally. You know, sometimes their jobs are on the line, but it is really important to recognise that it is a process
that is frequently very difficult, both, I mean obviously we don’t know the impact of this sort of assessment processes yet. But the inspection and all the different assessments that are happening are very stressful for pretty much everybody on the front line at the very
least. It is our job, that is what we have got to do and I recognise that we are trying to do that in an improved way and in a collaborative way, but I think it is just important to keep in mind that this is
always going to be difficult for people who are on the receiving end
Mr Ian Dilks - 2:07:22
of it. Stephen. Thank you Joyce. A really helpful report and I think
Mr Stephen Marston - 2:07:28
it is a really good example of sort of learning from other sectors to reflect on how we do what
we do. I very much welcome what you were saying about building into our own training. Just sort of thinking about awareness of the psychological effects on the people that we are dealing with, so that we get better at spotting states of distress. I think
that is a really positive move, it is what Ofsted have done. I think we should also be training our people similarly. Secondly, sort of the issue about consistency. In any regulator or inspector which is dependent on very large numbers of people supposedly applying a
standard methodology in a standard way, but actually inconsistency always creeps in, so continuing to think about, how do we know that our intended approach is being carried out consistently in each case? Because I think, part of the learning from Ofsted is that the effect
on the provider can too often be dependent on the particular inspection team you get. So, thinking about consistency. Then the third point, I really welcome Joyce what you were saying about the importance of understanding the experience of providers of our new Single Assessment Framework,
but hoping, and I’m sure this is the intention, that kind of that isn’t just about the technology and is it easy or difficult to upload stuff, and do you get the right data and so on? It is also kind of more profoundly, I think,
getting at is the experience of providers with a Single Assessment Framework genuinely getting them to believe that if they enter into all of this in the right spirit, not of fear and trepidation, but believing that they can learn from this themselves, and can improve
from this themselves in their own setting, that would be a really valuable and important thing. Because our ability to promote improvement in providers is very much dependent on whether they own the results of what we do with them and for them. Or go into
a state of fear and denial. Sorry, a very long-winded way of saying I really hope that the way we evaluate the effect of the Single Assessment Framework on providers will try to get at that experience of providers. Do they believe this is genuinely helping
them to get better? If so, I think we will be doing something hugely important. Thanks. Can I respond to that, if I may? I will respond to the first and second points, and maybe Tyson might want to talk to
Ms. Joyce Frederick - 2:10:36
consistency. You are absolutely right
that the training is going to be important for the psychological effects, but there are two types of training I describe in the paper. The ones for providers and maybe others that work with us, but also for Operations colleagues themselves who also face difficult situations
and perhaps only one-off situations, but some of the things that come flooding through the doors on a continuous basis which can be particularly stressful for our own Operations Colleagues. So, there is two types of training that is being described here. Then the second issue,
I think you are absolutely right. The movement of improvement, if you like, happens when providers trust what we say and have confidence in the judgements that we make, and then make the improvements themselves. So, there are two parts of that. First of all, it
is really key to get our judgements right because, at the end of the day, there are people using services. So, if the judgements are right, then we can make progress. Secondly, if regulation is seen as being part of a continuous cycle of improvement rather
than something that comes to say, you are not doing something right, but it is that continuous cycle. Then, we are only going to get health and social care improving for everyone, rather than regulation being seen as something else. It is part, I would say
this, – I am the Director of Policy and Strategy - but regulation is part of that cycle of improvement, from quality improvement all the way through to the support that regulation can provide to providers and the system and others to make improvements themselves. Tyson,
I think you wanted to come in with a response and then two of the
Mr Ian Dilks - 2:12:07
three Marks on here. Can we after that I think, close it down unless there is anything burning? But, Tyson, do you want to go first with a response? I wanted
to pick up on a couple of Stephen’s points, and then, I think Chris
Mr Tyson Hepple - 2:12:21
will pick up on the provider point. On the training, I think, I have been working closely with our Academy on what this might look like, and I think we are close
to coming up with a proposal which will go to the People and Culture Committee soon. It is built around empathy, strategies for how to deal with people who demonstrate demonstrating signs of distress, but also importantly, I think, for our own people, self-care and how
to do a proper debrief after they have been involved in what is, clearly, a very uncomfortable situation. I am hoping that we can start to roll that out really relatively soon. I am kind of looking at May at the moment, but let’s see what
the discussion with the People and Culture Committee comes to. On consistency, I think one of the one of the advantages of the Single Assessment Framework is that we are scoring evidence categories at a fairly granular level. So, the report will be built up from
evidence which is captured at quite a local level. I also think that we have much better transparency of data at the moment, including how reports are being written, how people are rating particular evidence categories, that we can use our quality assurance mechanisms to try
and see if we are behaving in a consistent manner. So, I think that will help in that regard as well, but you are right, that is a really important point. Ian, sorry, I think you wanted a quick comment as well. Yes. Just I think
Mr Ian Dilks - 2:13:39
to fill in Tyson’s point, this incremental up and incremental down, I
Mr Ian Trenholm - 2:13:42
think, avoids the sort of the big surprise of why things have changed, so we should be able to say someone, OK, actually you are good, but you are starting to drift. So, therefore
it is less of a surprise. This Point 1, a sort of technical point, which I think is a big Single Assessment Framework plus. I think an area that I know that Ofsted are also thinking about is having trained their teams in how to recognise
distress in providers, what do they then do? Because, you know, if you are a large hospital Chief Executive, you would work with your Board and others to seek support in a range of different ways. If you are an owner or operator of a domiciliary
care business, what do you do? I think there is probably something for us, perhaps in partnership with Ofsted and maybe other regulators, around connecting with third parties, with mental health charities and others to say, look, we have recognised an issue here, we would like
to sort of signpost you to someone else. Because I think there is a risk for us as a regulator, as we become a regulator, but we also, de facto, take on a some kind of employer, vicarious liability, which is not our role, and we
should be clear about that. But I think our teams, I know, would naturally want to help, so we need to give those teams some tools to tangibly help people as well. Thank you. Mark Chakravarty, then Mark
Mr Ian Dilks - 2:14:58
Chambers. Thank you, I will keep it very
brief. But, one, I just really welcome this report. I think actually,
Mark Chakravarty - 2:15:03
you know, you mentioned there that we are encouraging people to become a continuous learning environment and organisations. This is a role model, I think, of how we are trying to do that ourselves
and I hope it’s one of many that we start to actually think about how can we get learnings from, and advance them? I also welcome the fact that there are some very concrete ideas for how we can actually apply the learnings from this. And
it sounds from Tyson that there is even reassurance that we have got a plan within that to say OK, what does the training programme look like? I think it will be important just to revisit this, even very briefly, just to see, you know, three
months and six months in, have we made a difference in the way that we operate, have we got new support out of this, have we actually done that improvement? It doesn’t need to be weighty or heavy or require specific reporting, but just that check
in to say, did we make the difference that we hoped it would make?
Mr Ian Dilks - 2:15:54
Yes, and I would agree with that. This is incredibly important. I
Mr Mark Chambers - 2:15:58
think the proposed responses are the right ones and it is indicative, again, that you can draw learnings and insight
from situations which are distinct from yours. There is always learnings for everyone. So, I think the responses are right. I understand we weren’t talking about timelines today, but I think tracking it in the way that Mark has suggested would be helpful, because I think
that actually these are subtle and quite difficult interventions. This training is not going to be like the sort of training that we have, that we are routinely delivering. I think for it to be impactful, it has got to cover (unintelligible) and others that are
involved in inspections as well. So, it won’t be straightforward to deliver this, but it would be really important, and it certainly has my very strong support that we are doing this. It is good to see.
Mr Ian Dilks - 2:16:59
Thank you. OK. Thanks Mark. So, look, Joyce, thanks very much
for the paper. I think it has been really helpful, both as a model for looking at things, but also, you know, it does two key things. It explains, on the one hand, for those who sometimes look at Ofsted and us, and put us together
and we are not. We are very different in some ways. On the other hand, there is always something you can learn, and I think that has been taken on board. I think, Christine, in her comments made a really good point earlier that the existence
of this tragic case has changed the landscape in some of the people regulating. So, some of what we are doing, we are not trying to say that we – and I am making this point partly if any of our colleagues are listening online –
we are not suddenly saying that we have been doing it badly. We are just saying we need to respond to the fact that the world has changed. My albeit very limited experience in going to inspections is that our people are very good at this,
the ones I have come across. But it is stressful it is extra stressful if it is a care home because you have no notice. I have been there and seen the look of joy on the face of a care home manager when we walk
in and say we are from Ofsted. It is also really important for both care homes and independent sector, as it came up that day on the call I was on, because this is their livelihood. The rating, losing a rating or drop in the rating
can affect livelihood, so the stress is absolutely enormous. So, I think we recognise the changing environment and respond to it. What we do in the future, I think, can I leave it with you to think about that. I am not sure, I am dubious
about having a specific tracking mechanism for everything, but one way or another, I think it would be really helpful in a few months’ time, let’s say six rather than the next Board meeting, just to say with a (unintelligible) of six months of experience of
putting our people through the programme. I mean, they will have their own views and they will have better feedback than us on how care home providers, in particular, are responding to the Ruth Perry case. And in doing so, I think it would be quite
helpful to have that sort of feedback if we could capture that as an action. So, thank you very much Joyce. We will move on to just, finally, a few governance things. So, Jeremy, can I turn to you just for a quick oral update on
anything from the last direct meeting? Thank you, Chair. So, I just want to give some feedback from the last direct meeting held in December. I think it is worth just pausing slightly and breaking this down into financial years. So, our accounts for the year
ending March 23rd are not yet finalised. This was anticipated and it is caused, in common with a number of other organisations, about a delay in the order of Local Authority Pension Schemes which are partly incorporated in our accounts and a material item for us.
So, we cannot complete our own accounts until that is done, and that is likely to be a few months away yet, or will be a few months away yet. But, having said that, the work to finalise our annual report and accounts is pretty much
there, just subject to those final changes, and the NAO have been doing our audit and, so far to date, nothing untoward has been identified. So, we are progressing, although this long delay is not helpful for anybody very much, so we do have to reflect
on how we can adjust the final ARAC to make sure that people understand the delay and why it has happened. Looking now to the current financial year and firstly looking at internal audit, the good news is our plan is proceeding as desired. In the
last Committee meeting, we discussed three reports, stakeholder engagement, confidentiality and access management, and governance and
Mr Jeremy Boss - 2:20:34
assurance arrangements. A number of recommendations were raised for all three of those, but I don’t think there is anything in particular I need to draw attention to the Board,
and individual management responses have been received and plans are in place to follow up on those actions. The next thing we look at is the progress on the existing bank of actions, and that has come up in our private Board meeting this morning and
there is good progress on that. We still have a little bit to do, but the Audit Committee is very much focusing on the ones that are missing the deadlines, the ones that require extensions, and indeed the ones that have been hanging around for a
long time and actually may now not really be relevant in the way in which they were originally phrased. So that is a continuing progress, but we are in a reasonably good shape. I think it is just worth noting on a balance of transparency that
we are changing our internal auditors. We have appointed the Government Internal Audit Agency to be our internal auditors from April, and indeed at the same time, we have given notice to our current internal auditors, PricewaterhouseCoopers, who have been in that role for probably five
years now. So, I should just note thanks to their work and anticipating a good finalisation of the current plan and handover to GIAA. The next phase we look at is risk and risk management and we have updated and looked at all the risks, particularly
looking at those that are not progressing back to green in the way we would like, and that’s a continued role for the Audit Committee. We also had a chance to have a look at the new Risk Management System that is being developed which should
give us a much easier way to manage progress, show what we are doing and I think will be a real step forward, and that is pretty complete now. It just needs to have all the data put in it, but we will get there. Then
we also looked at transformation, particularly important at this time where we are in the programme, to give additional assurance to the Board that the relevant controls and processes are in place, and there’s a specific role for the Audit Committee on approving and monitoring use
of contingent labour and we discharge that, again no issues to raise. There were four things we also looked at – it was a busy meeting. An update from Healthwatch England and the National Guardian’s Office, actually both of the presentations earlier in this meeting reference
back to that. We also looked at cyber resilience and our work on that, and I think it is worth noting that we genuinely feel that we are in a much stronger position in the last year or so as we have rolled out the new
technology and also adapted to the threats we see. So fingers crossed, there has been good progress there which gives us some assurance that we are on top of that, always been aware that the risk is changing all the time. So, not complacent but in
a good place. Then, finally, counter fraud where we are doing some extra work to look at the new government functional standards around that and make sure we are aligned. In a fraud sense, we are not a particularly large organisation so we need to be
proportionate, but there is work underway to do that. So that was the update of the meeting unless anyone has any questions. Alright, no questions can I just add, one thing you didn’t mention obviously, it
Mr Ian Dilks - 2:23:50
has been (unintelligible), we have a newly-appointed chair of the
ARAC, so we have arrangements in hand to effect a smooth handover, but Jeremy, on behalf of the board, I would just like…, I know everyone thinks you have done a fantastic job. Very difficult to ask you to stand in and we very pleased we
asked you to cover that interim period, but can I just say thank you on everyone’s behalf for the work you have done. We do appreciate it. Mark, a brief oral update on RGC please. Yes, very happy to do that, thank you, Chairman. As a
Mr Mark Chambers - 2:24:29
reminder, the RGC is sort of broken into two parts. We look at a regular core paper where we look at the changes to the design, we look at the delivery and we look at the measures that we have, indicators we have about the effectiveness
of our regulatory model so that is the first part. Then the second part, we generally do a deep dive on a particular topic that we would not have time to talk about at Board. I think the key thing is…, actually a lot of what
came up in the core paper we have covered today, so I won’t cover that today. More than any other RGC I have experienced, the same things came up on Board today, but it was a much improved paper, so thank you to the Executive Team
for the effort in getting us to a smarter, smaller deck that much more clearly gave visibility to the issues that are concerning management. I think it allowed us a more focused meeting as a result. I think of all the things…, and you know, the
metrics that are in there are better, but they will continue to evolve as the Single Assessment Framework and our new methodology for regulation beds in, we will find the right measures that give us the insight that we need at the Committee. I think, probably,
of all the things that we talked about today, the only thing that would…, perhaps just one thing I would mention was, just as a mirror to the update on the LLRC actions, there have been quite a lot of recommendations that we have accepted over
the years from a variety of sources. So, the ones that are not in the LLRC, we are trying to track those that are at RGC. You know, it is a similar story. More than half of those are delivered or close to completion, but at
the next meeting will have a closer look at the ones that are stalled to understanding, again, is that for good reason, or are we just having difficulty getting them going? The deep dive was, you know, was on whistleblowing which I hope gives those joining
the meeting remotely some assurances as to how important it is to us. We have got to make sure that people feel a maximum level of confidence in raising issues and concerns directly with us. We were encouraged to see the enhancements and improvements that we
are trying to drive in that space. Our next meeting is 17th April.
Mr Ian Dilks - 2:27:40
Thank you Kate. A couple of final matters. We have got the minutes of the last meeting in the pack that were circulated before - what you have in front of you is
what was circulated, so can I take those as approved? Thank you very much. We have in the pack the action log, two items are shown as outstanding, but on track and not yet due, two are shown as closed, one is closed by virtue of
the fact that there has just been acceptance, something we have done on an ongoing basis, so I suggest that is closed. So, I am happy with that log if everyone else is? I think in terms of the formal business then, that brings us to
any other business. So is there anything else anybody wanted to raise? I don’t think I have missed anybody, OK. Well, look, thank you very much indeed, colleagues, sorry, we are a few minutes late, but only just, but thank you very much indeed. There is
some good discussions there and a few things to follow up on. That is the end of the formal business, but as usual we do offer members of the public the opportunity to ask questions. So we have only got three today and I am going

7.0 Any Other Business

to ask Chris and Tyson to respond to them. I hope you have been forewarned, if not, you will have to make it up as you go along. The first question is one for you, Chris, how will the work of CQC change during the period
of a UK General Election? Thanks for the question. So, in accordance
Chris Day - 2:29:15
with Cabinet Office guidance, ALBs, during the pre-election period, are asked to really hone down to discharge their regulatory functions only. But for us our regulatory functions are inspections of providers and, obviously, inspections
of local authority and ICSs. What we have done in the past, particularly for ICSs and LAs is not publish those documents during the pre-election period, but still carry out the activity. So, it wouldn’t stop our regulatory activity, it wouldn’t stop us taking enforcement action
if we felt that we needed to protect people who use services, but we would not seek to publish those documents and actually, as we are developing our plan for this, over that short period of time which is the formal pre-election period, we wouldn’t choose
to publish it at a system level, but still carry on at a provider level. We will do that sort of in cooperation with the Cabinet Office. The Cabinet Office, as we get closer to an election, will set out the
Mr Ian Dilks - 2:30:19
actual days of a pre-election
period. So, they are not determined yet and they are slightly at the
Chris Day - 2:30:24
behest of the Cabinet Office, but we will work with that data and that guidance when it comes out. So, somebody might shift the delivery of some things about the core business carries
Mr Ian Dilks - 2:30:32
on as usual, basically. The next question is for you as well Chris, interesting one. What communications are there with the Secretary of State concerning serious issues in NHS services? So, it is important
Chris Day - 2:30:48
that we are able to share our concerns with all services, but
particularly for the NHS, with senior partners, including the Secretary of State. So, we would regularly share with her and her team, a wider team, any serious concerns that we had around NHS services and anything where we are due to take action which would result
in a change to the way that service operates, but we wouldn’t just share it with her, we would share it with colleagues in NHS England because they may well be responsible for the action that follows our action. So, we would absolutely and do on
a regular basis, share our concerns, particularly with other colleagues who have responsibility for those services, nationally. Then, we will use that too as a pre-empt for anything that we put out to the public and the wider media. OK, thank you, Chris. The last question is
Mr Ian Dilks - 2:31:41
one for you, Tyson, rather more specific, how does the CQC currently engage with the prison inspections to regulate their health services? Thank you for the question. We have statutory powers to register,
Mr Tyson Hepple - 2:31:55
monitor and inspect regulated health activities delivered by health providers in the prison
estate. As the quality of healthcare may be impacted by the effectiveness of the wider prison regime, we adopt a partnership approach with HM Inspectorate of Prisons to deliver the prison inspection through a joint inspection framework. During these joint inspections we inspect the delivery of
healthcare and HMIP inspect the treatment of prisoners and wider conditions. Each inspection leads to a joint report. Should our inspection activity identify breach of healthcare standards, then a separate report will set out our evidence of breach and any action we are taking. There may
be situations where we will inspect as a single agency if the evaluation of risk determines that a separate on-site inspection is required, but in summary, we work very closely with the Inspectorate of Prisons. Thank you. OK, thank you Tyson. So, that is all of
Mr Ian Dilks - 2:32:52
the questions, I hope that answered them, satisfactorily, for those that asked them. So, we have already closed the meeting. I think that is it for the questions. So, for anyone listening in, thank you for doing so and we will see you at the next
meeting at the end of March. Thank you.